HUNTINGTON VALLEY HEALTHCARE CENTER
For profit - Limited Liability company
144 Beds
PACS GROUP
Data: November 2025
Trust Grade
40/100
#1044 of 1155 in CA
Photo by Google Maps
Photo by Huntington Valley Healthcare
Photo by Huntington Valley Healthcare
Photo by Huntington Valley Healthcare
1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Huntington Valley Healthcare Center has a Trust Grade of D, indicating below-average care with some concerning issues. It ranks #1044 out of 1155 facilities in California, placing it in the bottom half of nursing homes statewide, and #68 out of 72 in Orange County, meaning there are very few local options that are worse. The facility's performance is worsening, with the number of issues reported increasing from 15 in 2024 to 36 in 2025. Staffing is a significant concern, with a low rating of 1 out of 5 stars and a high turnover rate of 54%, which is above the California average. Although the facility has not received any fines, there are serious sanitation issues, such as the use of expired food, improper food handling, and a lack of staff adherence to hand hygiene protocols, which could risk the health of residents. Overall, while there are no fines and the facility has some average quality measures, the issues with staffing and sanitation are significant weaknesses that families should carefully consider.
- Trust Score
- D
- In California
- #1044/1155
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 109 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 10%
No red flags
15 → 36 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 15 issues
2025: 36 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below California average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 54%
Near California avg (46%)
Higher turnover may affect care consistency
Chain: PACS GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 109 deficiencies on record
Sept 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary tr...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary treatment and services for the provision of parenteral fluids (liquids administered to the body, most commonly via a vein (intravenous, to provide hydration, correct the electrolyte imbalances, deliver nutrients, or administer the medications when normal oral intake is not possible) for one of six sampled residents (Resident 1). * The facility failed to ensure Resident 1's intravenous fluids (IVF) was administered and documented as per the facility's P&P. This failure had the potential to negatively affect Resident 1's health and well-being. Findings: Review of the facility's P&P titled Intravenous Administration of Fluids and Electrolytes dated 2001 showed the resident should be monitored frequently, per facility policy, when continuous fluids are infusing for signs and symptoms of fluid overload, catheter patency, insertion site complications, and resident's tolerance of procedure. The following information should be recorded in the resident's medical record including: 1. The date and time the infusion was administered;2. The type of solution administered;3. The amount of solution administered;4. The route of administration;5. The rate of administration;6. The condition of the IV site before and after administration;7. Notification of the provider if there are any complications;8. How the resident tolerated the procedure; and9. The signature and title of the person recording the data. The P&P further showed to notify the provider, supervisor, and on the coming shift of complications or resident refusal of treatment. Report other information in accordance with facility policy and professional standards of practice. Medical record review for Resident 1 was initiated on 9/3/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's progress note dated 9/5/25 at 1315 hours, showed LVN 4 received a new physician's order for STAT labs and IVF NS (normal saline) at 75 ml per hour until labs get back. LVN 4 documented the orders were noted and carried out. However, further review of Resident 1's progress notes failed to show documented evidence the IVF was administered to Resident 1. The progress notes also failed to show if the physician was notified if the IVF was not administered. Review of Resident 1's MAR for September 2025 showed the following physician's order dated 9/5/25 at 2021 hours:- may call IV Experts for IV insertion due to poor venous access; and - to transfer Resident 1 out to Acute Hospital A for further evaluation of decreased urine output and increased lethargy (state of extreme tiredness, lack of energy, and sluggishness). Review of Resident 1's Order Summary Report and MAR for September 2025 failed to show a physician's order for the normal saline IVF ordered on 9/5/25 at 1315 hours. On 9/18/25 at 1550 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 2. RN 2 verified the above findings. When asked if the normal saline IVF was documented on the MAR, RN 2 verified there was no documented evidence the IVF and/or the IV site monitoring were noted on the resident's MAR. RN 2 stated she recalled being able to insert a peripheral IV on Resident 1's left thumb area on 9/5/25 at approximately 1400 hours and starting the IVF. However, RN 2 verified there was no documented evidence to show the IV peripheral was inserted and the IVF was administered as ordered by the physician. On 9/18/25 at 1630 hours, an observation and concurrent interview was conducted with RN 2. When asked to show documented evidence the normal saline IVF was removed from the facility's IV E-kit and administered to Resident 1 on 9/5/15, RN 2 stated she had to check the facility's medication rooms for the record. RN 2 stated the facility had two nursing stations and the protocol for removing medications from the E-kit would be to complete a form and place the copy of the completed form in the E-kit and another copy would be kept at the facility. After observations of both nursing stations were conducted with RN 2, RN 2 verified there was no documented evidence a form was completed to show the normal saline IVF was removed from the E-kit on 9/5/25 for Resident 1. On 9/18/25 at 1712 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. On 9/19/25 at 1219 hours, a telephone interview was conducted with the IV Department Supervisor at Pharmacy A stated there was no documented evidence a form was completed by the facility staff to show the normal saline IVF was removed from the facility's IV E-kit for Resident 1 on 9/5/25. The IV Department Supervisor at Pharmacy A stated the process when the facility staff removed an IV medication from the IV E-kit would be to complete the form. A copy of the complete form would be kept in the E-kit and another copy would stay in the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary ph...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage of the medications for one of six sampled residents (Resident 2). * The facility failed to ensure Resident 2 had no medication stored at the bedside. This failure had the potential for Resident 2 to administer the medication inaccurately.Findings: Review of the facility's P&P titled Self-Administration of Medications revised 2/2021 showed any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. On [DATE] at 0941 hours, an observation was made in Resident 2's room. One tube of diclofenac sodium 1% topical gel (medication that treats arthritis/osteoarthritis) was observed on the top drawer of Resident 2's bedside drawer with a fill date of [DATE], and had expired on 11/2023. Resident 2 was observed to be in the room. Medical record review for Resident 2 was initiated on [DATE]. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated [DATE], showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's Nursing - Self-Administration of Mediation Observation dated [DATE], showed Resident 2 did not want to self-administer medications. Review of Resident 2's Order Summary Report dated [DATE], showed no physician's order for the diclofenac sodium 1% topical gel (pain medication). Further review of Resident 2's medical record failed to show documentation Resident 2 could store the diclofenac medication at the bedside. On [DATE] at 0945 hours, an observation, interview, and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 reviewed Resident 2's medical record and verified there was no physician's order or care plan allowing the resident to store the medications at the bedside. RN 1 verified Resident 2's Self-Administration of Medication assessment dated [DATE], showed the resident did not want to self-administer the medications. RN 1 stated the resident's family member may have brought in the medication and the facility would contact the family. RN 1 further stated the medication needed a physician's order prior to administering the medication and should not be left unattended at the resident's bedside because the facility staff would not be able to assess for proper administration of the medication by the resident. On [DATE] at 1029 hours, an interview with Resident 2 was conducted with RN 1 and CNA 4 present. Resident 1 requested CNA 4 to translate in Vietnamese. Resident 2 stated the diclofenac medication was provided by her family. When Resident 2 was asked when the diclofenac medication was brought in by her family, Resident 2 stated she did not recall. On [DATE] at 1135 hours, an interview was conducted with the DON. The DON stated the medications could be left at the resident's bedside if there was a physician's order, care plan, and an evaluation to self-administration the medications. The DON stated the other residents or facility staff could use the medication not intended for their use, if the medication was left unattended at the resident's bedside. On [DATE] at 1712 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the laboratory tests for one o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the laboratory tests for one of six sampled residents (Resident 1) was performed as ordered. * The facility failed to ensure Resident 1's physician's order for stat CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) were completed as ordered. This failure posed the risk for Resident 1 not receiving the appropriate treatment, which could significantly impact the resident's well-being.Findings: Review of the facility's P&P titled Lab and Diagnostic Test Results - Clinical Protocol revised 11/2018 showed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider, or other testing sources will report test results to the facility. The P&P further showed a nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. The P&P further showed the nurse will try to determine whether the test was done to assess a condition change or recent onset of signs and symptoms. Moreover, the P&P showed the nursing staff will consider the following factors to help identify situations requiring prompt physician notification concern lab or diagnostic test results: - Whether the physician has requested to be notified as soon as a result is received.- Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors).- Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Medical record review for Resident 1 was initiated on 9/3/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report for September 2025 showed the following physician's orders:- dated 9/5/25 at 1315 hours, for stat CBC and CMP. - dated 9/5/25 at 2021 hours, to transfer the resident to Acute Hospital A for further evaluation of the decreased urine output and increased lethargy. Review of Resident 1's medical record failed to show documented evidence Resident 1's physician's order for stat CBC and CMP were completed. On 9/17/25 at 1607 hours, an interview was conducted with LVN 2. LVN 2 stated stat laboratory orders should be done as soon as possible, typically within two hours. LVN 2 stated it was also depended on when the laboratory technician arrived at the facility. LVN 2 stated if the physician's order was ordered as stat and the laboratory tests were not drawn at a certain time or if the laboratory technician could not make it to the facility stat, then she would notify the physician and document in the resident's medical record. In addition, LVN 2 stated for stat laboratory orders, the facility had to enter the physician's order into the facility's PCC (Point Click Care) system and laboratory's portal system and also call the laboratory to inform them of the stat order. On 9/18/25 at 1135 hours, an interview was conducted with the DON. The DON stated stat laboratory tests were done in a ‘timely manner, with no specific time; however, the DON stated the laboratory company would say the best practice is four hours. The DON further stated if the laboratory would take an extended time to draw the specimen, she expected the licensed nurses to call and follow up with the laboratory to determine the estimated time the laboratory technician would arrive. The DON stated she also expected the licensed nurses to document the follow up with the laboratory and physician if the laboratory would not be able to complete the ordered tests as stat. On 9/18/25 at 1437 hours, a telephone interview was conducted with the Hospital Lab Assistant. The Hospital Lab Assistant stated stat laboratory tests were done within two to four hours but also depended on the technician's availability in the area. The Hospital Lab Assistant stated to process stat laboratory orders, the facility needed to also call the laboratory company to inform them of the stat laboratory order. When asked if the laboratory received a stat order for Resident 1, the Hospital Lab Assistant stated they did not and stated the last blood work was completed on 8/22/25. On 9/18/25 at 1515 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified he received the physician's orders for Resident 1's stat CBC and CMP on 9/5/25 at 1315 hours. LVN 4 verified the laboratory portal did not show the stat laboratory results for Resident 1. When asked if he saw the laboratory technician arrive after the stat laboratory was ordered, LVN 4 stated he did not see the laboratory technician prior to the end of his shift on 9/5/25. On 9/18/25 at 1712 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of six sampled residents (Resident 1) was complete. * The facility failed to ensure Resident 1's TAR for August 2025 was complete regarding the monitoring of the resident's urine characteristics. This failure had the potential to result in inadequate care due to an incomplete medical record for Resident 1. Findings: Review of the facility's P&P titled Catheter Care, Urinary revised 5/2024 showed the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. The P&P further showed information should be recorded in the resident's medical record including character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. Medical record review for Resident 1 was initiated on 9/3/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed a physician's order dated 8/13/25, for Resident 1's Foley catheter size16 Fr 10 ml and to change as needed. Review of Resident 1's TAR for August 2025 showed a physician's order dated 8/14/25, for the indwelling urinary catheter and to monitor for change in the urine character. However, the TAR was blank on 8/15/25 for the evening shift and 8/22/25 for the night shift. On 9/18/25 at 1400 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings. LVN 3 stated when the TAR was left blank, it meant it was not documented. LVN 3 stated the monitoring for the change in the urine character should have been documented if it was completed. On 9/18/25 at 1532 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 verified the above findings. LVN 5 stated the licensed nurse might have monitored for the resident's urine characteristics for the evening shift on 8/15/25, and on the night shift on 8/22/25, but might have forgotten to document on the resident's TAR. LVN 5 stated it should have been documented if it the monitoring was done as ordered. On 9/18/25 at 1712 hours, an interview was conducted with the Administrator and DON. The DON stated she expected the licensed nurses to follow the physician's orders. The Administrator and DON were informed and acknowledged the above findings.
Jun 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical records for three of eight sampled resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical records for three of eight sampled residents (Residents 1, 2, and 3) were accurate and complete.
* Resident 1's POLST did not show the physician's phone number, license number, signature, or the resident's responsible party's signature, address, and telephone number. In addition, the responsible party's signature was written in by the nurse filling out the form and did not indicate it was a verbal consent. Additionally, the NP's name was written in the section where the NP's supervising physician's name should have been.
* Resident 2's POLST did not show the NP's phone number, license number, date signed, or the name of the NP's supervising physician. In addition, the POLST did not indicate if the NP had discussed the information with Resident 2. Resident 2's POLST did not show the resident's address and telephone number, and the resident's signature was undated. Additionally, the POLST did not show the title of the preparer's name or phone number.
* Resident 3's POLST did not show the verbal consent given by the resident's responsible party was witnessed by a second nurse. In addition, the POLST did not show Resident 3's wishes in regard to artificially administered nutrition and the resident's responsible party's address and phone number.
These failures had the potential for the residents' care needs not being met as their medical information was incomplete and/or inaccurate.
Findings:
According to Californiapolst.org, a POLST is a medical order that helps give people with serious illness more control over their care during a medical emergency. The POLST helps to ensure people receive the care they want and protect them from getting medical treatments they do not want. The POLST form is not valid until signed by both the individual or the individual's responsible party, and a physician, nurse practitioner, or physician assistant.
1. Closed medical record review for Resident 1 was initiated on 6/16/25. Resident 1 was admitted to the facility on [DATE], and discharged on 5/29/25.
Review of Resident 1's H&P examination dated 5/21/25, showed Resident 1 had a diagnosis of dementia.
Review of Resident 1's MDS assessment dated [DATE], showed the resident had moderate cognitive impairment.
On 6/16/25 at 1322 hours, an interview and concurrent medical record review was conducted with RN 2. Review of Resident 1's POLST dated 5/20/25, showed under Section D - Information and Signatures, the physicians name, telephone number, license number, signature, and date were left blank. In addition, review of Resident 1's POLST dated 5/20/25, showed under Section D - the residents responsible party's signature and cosigned by the nurse filling in the form. Resident 1's POLST did not show the words verbal consent, nor was the verbal consent witnessed by a second nurse. Additionally, review of Resident 1's POLST showed the responsible party's mailing address and telephone number were left blank. Resident 1's POLST also showed under Section D- Information and Signatures, the name of the NP was written in the section intended for the name of the NP's supervising physician. RN 2 verified the findings.
2. Medical record review for Resident 2 was initiated on 6/16/25. Resident 2 was admitted to the facility on [DATE].
Review of Resident 2's H&P examination dated 6/9/25, showed Resident 2 had the capacity to understand and make medical decisions.
Review of Resident 2's MDS assessment dated [DATE], showed the resident had moderate cognitive impairment.
On 6/16/25 at 1322 hours, an interview and concurrent medical record review was conducted with RN 2. Review of Resident 2's POLST dated 6/8/25, showed under Section C - Artificially Administered Nutrition, was left blank and did not show if the information was discussed with the resident. In addition, review of Resident 2's POLST showed under Section D - Information and Signatures, the NP's telephone number and license number, and the resident's mailing address and telephone number were left blank and undated. RN 2 verified the findings.
3. Medical record review for Resident 3 was initiated on 6/16/25. Resident 3 was admitted to the facility on [DATE].
Review of Resident 3's H&P examination dated 2/9/25, showed Resident 3 had the capacity to understand and make medical decisions.
Review of Resident 3's MDS assessment dated [DATE], showed the resident was cognitively intact.
On 6/16/25 at 1322 hours, an interview and concurrent medical record review was conducted with RN 2. Review of Resident 3's POLST dated 2/8/25, showed a verbal consent from Resident 3's responsible party was obtained on 2/8/25, and was initialed by the nurse who took the verbal consent. Resident 3's POLST did not show the verbal consent was witnessed by another nurse. RN 2 stated two nurses were required to cosign a verbal consent, the nurse who receives the verbal consent and a second nurse to witness the consent. RN 2 confirmed the verbal consent was not cosigned by a witness. In addition, review of Resident 3's POLST dated 2/8/25, showed under Section C - Artificially Administered Nutrition was left blank and did not show if the information was discussed with Resident 3's responsible party. Additionally, review of Resident 3's POLST dated 2/8/25, showed under Section D - Information and Signatures, the responsible party's mailing address and telephone number were left blank. RN 2 verified the findings.
On 6/19/25 at 1545 hours, an interview was conducted with the DON. The DON confirmed the above findings.
Apr 2025
24 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the safe self-adm...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the safe self-administration of medication for one nonsampled resident (Resident 41).
* Two bottles of Systane eye drops (medication to temporarily relieve dry, irritated eyes) were kept at Resident 41's bedside table. Resident 41 had self-administered the Systane eye drop medication after being assessed to not self-administer her medications. This failure had the potential for the resident to administer the medications inaccurately and negatively affect the resident's physiological well-being.
Findings:
Review of the facility's P&P titled Self-Administration of Medications revised on 2/2021 showed the following:
- As a part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident;
- If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan;
- Residents who are identified as being able to self-administer medications are asked whether they wish to do so;
- For self-administering residents, the nursing staff determines who is responsible (the resident or the nursing staff) for documenting that medications are taken; and
- Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.
During the initial tour of the facility on 4/1/25 at 0808 hours, an observation and concurrent interview was conducted with Resident 41. Resident 41 was observed in bed. Two bottles of Systane eye drop medication were observed on top of Resident 41's bedside table. Resident 41 stated she did administer the Systane eye drops to herself.
On 4/1/25 at 1559 hours, an observation and concurrent interview for Resident 41 was conducted with LVN 10. LVN 10 verified the two bottles of Systane eye drop medication were on Resident 41's bedside table. LVN 10 stated Resident 41 was not able to administer the eye drop medication on her own. LVN 10 stated Resident 41 could not keep the Systane eye drop medication at the bedside.
Medical record review for Resident 41 was initiated on 4/3/25. Resident 41 was admitted to the facility on [DATE].
Review of Resident 41's H&P examination dated 10/11/24, showed Resident 41 had no capacity to understand and make decisions.
Review of Resident 41's Self-Administration of Medication Observation form dated 1/10/25, showed Resident 41 was assessed and did not want to self-administer the medications.
Review of Resident 41's Order Summary Report dated 4/3/25, did not show the physician's orders for the Systane eye drops and for Resident 41 to self-administer the medications.
Review of Resident 41's plan of care did not show a care plan problem to address Resident 41's eye problem and her ability to self-administer the Systane eye drop medication.
On 4/7/25 at 1339 hours, an interview and concurrent medical record review for Resident 41 was conducted with the DON. When asked for the facility's process for the resident to self-administer the medications, the DON stated the physician's orders, care plan, and assessment for self-administration of the medication for Resident 41 were needed. The DON verified there were no physician's orders and care plan for the self-administration of the medication for Resident 41.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 97 was initiated on 4/1/25. Resident 97 was admitted to the facility on [DATE].
Review of...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 97 was initiated on 4/1/25. Resident 97 was admitted to the facility on [DATE].
Review of Resident 97's Physician Orders for Life-Sustaining Treatment (POLST) dated 1/28/25, under Section D Information and Signatures showed no advance directive was selected. However, the section for Health Care Agent if named in the Advance Directive showed Resident 97's responsible party.
Review of Resident 97's Social History assessment dated [DATE], showed Resident 97 had no advance directive nor power of attorney, and the resident's family would like assistance in obtaining one.
Review of Resident 97's H&P examination dated 1/30/25, showed Resident 97 did not have the mental capacity to make decisions.
Review of Resident 97's medical record failed to show the Advance Healthcare Directive Acknowledgement form. Additionally, further review of Resident 97's medical record failed to show the documented evidence Resident 97's responsible party was provided with the information on formulating the advance directive.
On 4/3/25 at 1600 hours, an interview and concurrent medical record review for Resident 97 was conducted with the SSD. The SSD verified the above findings. The SSD stated if the resident had no capacity to make decision, the information on how to formulate an advance directive should still be offered to the resident's responsible party.
On 4/7/25 at 1403 hours, an interview was conducted with the DON. The DON stated upon admission to the facility, the facility staff was responsible for inquiring whether the resident had an advance directive. The DON stated if the resident or resident's responsible party indicated they wanted more information on how to formulate an advance directive, the DON expected the admitting nurse or the social services staff to provide the written material on how to formulate the advance directive. The DON further stated the facility staff should also document in the resident's progress notes that the information on how to formulate an advance directive had been offered to the resident or resident's responsible party.
On 4/7/25 at 1430 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.
3. Medical record review for Resident 88 was initiated on 4/1/25. Resident 88 was readmitted to the facility on [DATE].
Review of Resident 88's Advance Healthcare Directive Acknowledgement dated 11/27/24, showed Resident 88 had not executed an advance directive.
Review of Resident 88's Social History Assessment (Admission/Annual) - V 3.4 dated 12/23/24, showed Resident 88 had no advance directive and Family Member 2 was Resident 88's primary agent.
Review of Resident 88's MDS assessment dated [DATE], showed Resident 88 had moderate cognitive impairment.
Further review of Resident 88's medical record failed to show the documented evidence the facility followed up with Resident 88 and/or Family Member 2 to provide the information and assistance on formulating the advance directive.
On 4/3/25 at 0951 hours, an interview was conducted with RN 2. RN 2 stated part of the admission process, the RN had to check with the resident or their responsible party whether the resident had an advance directive. RN 2 stated the Advance Healthcare Directive Acknowledgement form would be provided to the resident or their responsible party. RN 2 stated if the resident or their responsible party indicated the resident did not have an advance directive, the social services staff would follow up with the resident to provide the written material on how to formulate the advance directive. RN 2 further stated the social services staff could also offer assistance on how to formulate the advance directive.
On 4/3/25 at 1417 hours, an interview and medical record review for Resident 88 was conducted with the SSD. The SSD stated if the resident or their responsible party indicated the resident had not executed an advance directive, the social services staff should provide the written material titled Your Rights to Make Decisions About Medical Treatment, which had the information on how to formulate the advance directive. The SSD further stated an assistance should be offered or provided to the resident or their responsible party on how to formulate the advance directive and should be documented in the resident's progress notes or in the social history assessment. The SSD verified there was no documented evidence Resident 88 and Family Member 2 were provided the information and offered assistance on formulating the advance directive.
On 4/4/25 at 1630 hours, an interview was conducted with the DON. The DON was informed and acknowledge the above findings.
Based on interview, medical record review, and facility P&P review, the facility failed to obtain and/or maintain the copies of the advanced directives (written statement of a person's wishes regarding medical treatment) and provide the written information regarding how to formulate the advanced directives for four of 28 final sampled residents (Residents 44, 88, 97, and 106).
* The facility failed to ensure a copy of the advance directive was available in Residents 44 and 106's medical record.
* The facility failed to provide the written information and assistance regarding how to formulate an advance directive for Resident 88.
* The facility failed to provide the written information regarding how to formulate the advance directive for Resident 97 was provided to the resident or responsible party.
These failures had to the potential for residents' to receive inaccurate and delayed treatment compatible with the residents' wishes during an emergent situation.
Findings:
Review of the facility's P&P titled Advance Directives revised on 5/2024 showed the following:
- The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy;
- Prior to or upon admission of a resident, the social service director (SSD) or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives;
- The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so;
- Written information includes a description of the facility's policies to implement advance directives and applicable state law;
- If the resident or representative indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advance directives;
- The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision;
- Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance;
- Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff; and
- If the resident or the resident's representative has executed one or more advance directive(s), or execute one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff.
1. Medical record review for Resident 44 was initiated on 4/7/25. Resident 44 was readmitted to the facility on [DATE].
Review of Resident 44's H&P examination dated 2/26/25, showed Resident 44 had the capacity to understand and make decisions.
Review of Resident 44's Advance Directive Acknowledgement dated 2/27/25, showed Resident 44 executed an advance directive.
On 4/2/25 at 1215 hours, an interview and concurrent medical record review was conducted with LVN 12. LVN 12 verified the above findings; however, LVN 12 stated Resident 44's advanced directive was not available in the resident's medical record or EHR. LVN 12 stated the SSD was responsible to follow up and obtain a copy of Resident 44's advanced directive. Furthermore, LVN 12 stated if the resident executed an advanced directive, a copy must be available in the resident's medical record or in the EHR.
On 4/3/25 at 1035 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the above findings and stated Resident 44's advanced directive was not available in the resident's medical record or EHR. The SSD stated she checked all the facility's residents advanced directive copies quarterly and when she was informed by the facility staff. Furthermore, the SSD verified there was no documented evidence a follow up was done to obtain a copy of Resident 44's advanced directive prior to 4/2025.
2. Medical record review for Resident 106 was initiated on 4/2/25. Resident 106 was admitted to the facility on [DATE].
Review of Resident 106's MDS dated [DATE], showed Resident 106's BIMS score was 11, indicating moderate cognitive impairment.
Review of Resident 106's Advance Directive Acknowledgement dated 12/27/24, showed Resident 106 executed an advanced directive.
On 4/2/25 at 1224 hours, an interview and concurrent medical record review was conducted with LVN 12. LVN 12 verified the above findings, however, LVN 12 stated Resident 106's advanced directive was not available in the resident's medical record or EHR.
On 4/3/25 at 1049 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified Resident 106's advanced directive was not available in the resident's medical record or EHR. The SSD stated Resident 106's advanced directive was discussed upon the resident's admission to the facility and must be revisited quarterly. Furthermore, the SSD verified there was no documented evidence a follow up was done to obtain a copy of Resident 106's advanced directive prior to April 2025.
On 4/7/25 at 1420 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to meet the professional standards of care for one nonsampled resident (Resident 370) observed for medication administration.
* LVN 1 failed to follow the proper procedure for the administration of insulin. This failure posed the risk for the resident to develop complications related to the inappropriate technique with the administration of insulin (used to treat high blood sugar).
Findings:
Review of the facility's P&P titled Insulin Administration revised 5/2024 showed the Steps in the Procedure (Insulin Injections via Syringe) section including to clean the injection site with an alcohol wipe and allow to air dry.
Review of the Administration Guide from the manufacturer of the Lantus insulin (undated) showed Step 4: Choose an Injection Site included the following:
- Decide on an injection area- either upper arm, thigh, or abdomen. Injection sites within an injection area must be different from one injection to the next;
- Use rubbing alcohol to clean the skin where you are going to inject. Alcohol can sometimes sting if it is not completely dry when you inject, so wait a few seconds for it to evaporate or pat the area dry with sterile cotton ball; and
- Pinch the skin and hold it. Insert the needle the way your healthcare professional showed you.
Medical record review for Resident 370 was initiated on 4/2/25. Resident 370 was admitted to the facility on [DATE].
Review of Resident 370's Order Summary Report showed a physician's order dated 3/26/25, to administer insulin glargine solution (Lantus) 100 units/ml 25 units subcutaneously (into the fatty tissue layer) two times a day for diabetes mellitus (high blood sugar).
On 4/2/25 at 0943 hours, a medication administration observation was conducted with LVN 1. LVN 1 stated Resident 370 was to receive the Lantus insulin 25 units subcutaneously. LVN 1 was observed wiping Resident 370's left upper quadrant of the abdomen with an alcohol wipe and injected the Lantus insulin right away while the injected area was still visibly wet. LVN 1 did not wait for the area wiped with alcohol to dry before injecting the insulin to Resident 370.
On 4/2/25 at 1426 hours, an interview was conducted with LVN 1. LVN 1 stated he received training regarding how to properly administer insulin or any injectable medications. LVN 1 stated prior to administering or injecting the insulin, the area where to inject the medication should be cleansed with alcohol and let it air dry. LVN 1 stated if the insulin was injected while the area was still wet with alcohol, it might sting and could cause pain to the resident, and it might alter the effect of the medication. LVN 1 verified Resident 370's left upper quadrant of the abdomen where he injected the insulin was not completely dry prior to administering the insulin.
On 4/3/25 at 1346 hours, an interview and concurrent facility personnel record review was conducted with the DSD. Review of LVN 1's Licensed Nurse Competency Evaluation Worksheet (Medication Administration-Injection) signed 7/6/23, showed LVN 1 was trained to clean the injection site with an alcohol pad by beginning at the center of the injection site and clean in a circular motion to extend two inches from the center of the injection site; and to allow the site to air dry (about one minute). The DSD stated when the area to inject the medication was not completely dried, it might sting and alter the effect of the medication. The DSD was informed and acknowledged the above findings.
On 4/4/25 at 1630 hours, the DON was informed and acknowledged the above findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary ca...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of 28 final sampled residents (Resident 21) and two nonsampled residents (Residents 57 and 101) as evidenced by:
* The facility failed to ensure the follow-up assessment and documentation were completed for Resident 21's foot scab and bilateral feet dryness.
* The facility failed to ensure Resident 57's post fall neurological assessment and monitoring were accurately completed after the resident had a fall on 3/16/25.
* The facility failed to ensure the attending physician was made aware regarding the recommendations from the acute care hospital for Resident 101 to be assisted in drinking the thickened liquid with a spoon. CNA 8 was observed using a plastic straw to provided assistance to Resident 101 when drinking the thickened liquids.
These failures posed the risk of the residents not receiving appropriate care and the potential for a delay in providing care to the residents.
Findings:
1. On 04/1/25 at 1225 hours, Resident 21's second right toenail was observed with a black circular mass underneath the toenail.
On 04/3/25 at 0816 hours, an observation and concurrent interview was conducted with LVN 7. When asked about the wound treatments performed to Resident 21's skin, LVN 7 stated she and Resident 21's wound care specialist provided wound care to Resident 21's right heel on 4/3/25. LVN 7 stated she did daily wound care treatments to Resident 21's right heel. LVN 7 verified Resident 21's second right toenail had a black scab on it and both Resident 21's feet had dryness. LVN 7 stated she was not aware of Resident 21's other feet conditions, other than the right heel wound.
Medical record review for Resident 21 was initiated on 4/3/25. Resident 21 was admitted to the facility on [DATE].
Review of Resident 21's Comprehensive Skin Evaluation/assessment dated [DATE], did not show Resident 21's right second toenail scab or bilateral feet dryness was addressed.
Review of Resident 21's podiatry visit dated 2/27/25, showed Resident 21 was treated for mycotic (caused by fungus) toenails and dryness to both his feet. Resident 21's podiatry recommendations included to apply lotion three to four times daily to restore moisture to Resident 21's feet.
3. On 4/1/25 at 0834 hours, an observation and concurrent interview for Resident 101 was conducted with CNA 8. Resident 101 was observed in bed and CNA 8 was observed assisting the resident with eating. CNA 8 stated Resident 101 was able to swallow the thickened liquids. A glass of thickened red color liquid with a white plastic straw was observed on top of the over bed table. CNA 8 stated Resident 101 was able to use the straw in drinking the thickened liquid but unable to hold the glass.
Medical record review for Resident 101 was initiated on 4/3/25. Resident 101 was admitted to the facility on [DATE].
Review of Resident 101's Discharge Summary from the acute care hospital dated 12/6/24, showed the Speech Therapy Treatment Note/Discharge Note dated 11/28/24, for diet and swallow recommendations. The recommendations were as follows:
- Nectar thick liquids,
- Aspiration precautions: sit upright while eating and drinking,
- Resident must be fed,
- Liquid by spoon only, and
- Maintain upright posture after eating for 30 minutes.
Review of Resident 101's Order Summary Report dated 4/3/25, showed a physician's order dated 2/26/25, for regular diet, pureed texture, and thickened liquid nectar consistency for oral gratification only as tolerated.
Further review of Resident 101's medical record failed to show documented evidence the Speech Therapy diet and swallowing discharge recommendations from the acute care hospital were communicated to the resident's attending physician and followed for Resident 101.
On 4/3/25 at 1340 hours, an observation and concurrent interview for Resident 101 was conducted with CNA 8. Resident 101 was observed in bed awake and CNA 8 was observed assisting the resident with eating. Resident 101's food tray and a glass of red color thickened liquid covered with a lid with a white plastic straw were observed on top of the over bed table. CNA 8 stated she assisted Resident 101 with eating and drinking. CNA 8 verified she used the white colored plastic straw to help Resident 101 drink the thickened liquid.
On 4/3/25 at 1352 hours, an interview and concurrent medical record review for Resident 101 was conducted with LVN 3. LVN 3 verified Resident 101 had a physician's order for pureed diet with thickened liquids. LVN 3 verified Resident 101's discharge summary recommendations from the acute care hospital included using spoon only for the thickened liquids. LVN 3 verified there was no documentation on the resident's medical record to show if the attending physician was made aware regarding the recommendations.
On 4/7/25 at 0936 hours, an interview and concurrent medical record review for Resident 101 was conducted with RN 1. RN 1 verified the physician's order for oral gratification diet order for Resident 101. RN 1 was asked if a straw was allowed to use for the residents who were on thickened liquids, RN 1 stated no. RN 1 verified the discharge summary recommendations from the acute care hospital for the resident's diet and swallowing precautions. RN 1 stated Resident 101 was seen by the ST in the facility. RN 1 acknowledged there were no documentation showing the swallowing recommendations from the acute care hospital for Resident 101 was communicated to the facility staff and resident's physician.
On 4/7/25 at 1012 hours, an interview and concurrent medical record review for Resident 101 was conducted with the DON. The DON was informed and verified the above findings.
2. Review of the facility's P&P titled Neurological Assessment revised on 4/2025 showed the following:
- Routine Neurological Assessment is conducted to evaluate the resident for small changes over time that may be indicative of neurological injury; and
- The following information should be recorded in the resident's medical record:
a. The date and time the procedure was performed;
b. The name and title of the individual(s) who performed the procedure;
c. All assessment data obtained during the procedure;
d. How the resident tolerated the procedure;
e. If the resident refused the procedure, the reason(s) why and the intervention taken; and
f. The signature and title of the person recording the date.
Review of the facility's P&P titled Change in a Resident's Condition or Status revised on 2/2021 showed the following:
- The nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident and significant change in the resident's physical/emotional/mental condition; and
- The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
Review of the facility's P&P titled Falls-Clinical Protocol revised on 5/2024 showed the facility staff and physician will continue to monitor and document the individual's response to the interventions intended to reduce falling or the consequences of falling.
Medical record review for Resident 57 was initiated on 4/3/25. Resident 57 was admitted to the facility on [DATE].
Review of Resident 57's H&P examination dated 3/11/25, showed Resident 57 had the capacity to understand and make decisions.
Review of Resident 57's MDS dated [DATE], showed Resident 57's BIMS score was 12, indicating moderate cognitive impairment.
Review of Resident 57's Neurological Assessments from 3/16 to 3/19/25, showed missing the Neurological Assessment results for the following dates and times:
- on 3/17/25, at 0130 hours, the left pupil response was not assessed;
- on 3/17/25, at 0530 hours, the left pupil response, extremities motor function, and pain response were not assessed;
- on 3/17/25, at 1730 hours, the Neurological Assessment was not completed;
- on 3/18/25 at 0130 hours, the Neurological Assessment was not completed; and
- on 3/19/25, from 0930 to 1790 hours, the Neurological Assessment was not completed.
Reviewed Resident 57's progress notes from 3/16 to 3/19/25, did not show the post fall monitoring was completed on the following dates and times:
- on 3/17/25, from the day shift (0700-1500 hours) to evening shift (1500-2300 hours);
- on 3/18/25, from the day shift to evening shift; and
- on 3/19/25, for the day shift.
On 4/7/25 at 0951 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON stated the Neurological Assessments must be completed by the licensed nurses to assess Resident's 57 neurological status post fall. Furthermore, the DON stated the post fall monitoring and documentation must be completed every shift for 72 hours.
On 4/7/25 at 1025 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the post fall monitoring must be documented to monitor Resident 57's condition and status. Furthermore, RN 1 stated the monitoring for the change of condition which included post fall, must be documented in Resident 57's medical record every shift for 72 hours and the Neurological Assessment must be completed to monitor the resident's neurological status.
On 4/7/25 at 1420 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to prevent the decline in the ROM functions for one of three final sampled residents (Resident 63) reviewed for prevention of ROM functions.
* The physician's order to apply an extension splint to Resident 63's left knee was not followed. In addition, Resident 63's skin was not assessed when the splint was applied. This failure had the potential for Resident 63 to sustain a decline in ROM functions, leading to muscle atrophy (loss of muscle mass and strength) and decrease in functioning.
Findings:
Review of the facility's P&P titled Restorative Nursing Services dated 5/2024 showed the restorative care will be provided to help promote optimal safety and independence.
During the initial tour of the facility on 4/1/25 at 1045 hours, an observation and concurrent interview with Resident 63 was conducted. Resident 63 was observed wearing the left lower leg splint. Resident 63 stated there were screws placed on his leg to align his leg.
Medical record review for Resident 63 was initiated on 4/7/25. Resident 63 was admitted to the facility on [DATE].
Review of Resident 63's Order Summary Report dated 4/7/25, showed a physician's order dated 3/27/25, to apply the left knee extension splint to the left knee everyday five times a week for up to five hours a day or as tolerated. However, there was no physician's order to include the skin assessment when the left knee splint was applied.
Review of Resident 63's plan of care showed a care plan problem (undated) addressing the potential decline in the resident's ROM functions and mobility. The interventions included the application of the left knee extension splint for up to five hours as per the physician's order. However, there were no interventions included in the care plan to perform Resident 63's skin assessment when the left knee splint was applied to the resident.
Review of Resident 63's Documentation Survey Report for April 2025 showed the RNA had applied the left extension knee splint to Resident 63. However, the record failed to show an accurate record of the time when the splint was applied and removed. In addition, there was no documented evidence the skin assessment was completed when the left knee extension splint was applied to Resident 63's left knee.
On 4/7/25 at 0908 hours, an interview and concurrent medical record review for Resident 63 was conducted with RNA 1. RNA 1 verified Resident 63 had RNA services ordered and the application of the left knee extension splint. RNA 1 was asked what time the left knee splint was applied to Resident 63. RNA 1 reviewed the medical record and stated the left knee splint was applied to Resident 63's left knee for five hours every day. RNA 1 verified there was no documentation of the exact time when the left knee splint was applied and removed from Resident 63's knee. RNA 1 was asked about Resident 63's skin when the left knee splint was applied. RNA 1 stated the RNAs checked the resident's skin after the left knee splint was taken off from Resident 63. RNA 1 verified and acknowledged there was no documentation about the skin assessment of Resident 63's left knee when the left knee splint was applied.
On 4/7/25 at 0931 hours, an interview and concurrent medical record review for Resident 63 was conducted with RN 1. RN 1 verified Resident 63's physician's order for the RNA services and the application of the left knee splint to Resident 63's left knee. RN 1 verified there was no physician's order to assess the resident's skin while the left knee splint was applied. RN 1 reviewed the RNA record and verified the hours of application for the left knee splint to Resident 63's knee was not documented, and the skin assessment was not included in the documentation. RN 1 stated a physician's order for the skin assessment at least every two hours should have been obtained and carried out to prevent any skin problem related to placement of the splint on the resident. RN 1 verified the care plan for the use of the splint did not include the skin assessment of the resident when the splint was in use.
On 4/7/25 at 1042 hours, an interview for Resident 63 was conducted with the DON. The DON was informed and verified the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 28 final s...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 28 final sampled residents (Resident 73) received the appropriate care and services for an indwelling urinary catheter. This failure had the potential for the resident to develop complications associated with the use of indwelling urinary catheter.
Findings:
Review of the facility's P&P titled Urinary Catheter Care revised on 5/2024 showed the following:
- Observed the resident for complications associated with urinary catheters; and
- Report unusual findings to the physician or supervisor immediately if urine has an unusual appearance like color, blood, etc. and if signs and symptoms of urinary tract infection or urinary retention occur.
Medical record review for Resident 73 was initiated on 4/4/25. Resident 73 was readmitted to the facility on [DATE].
Review of Resident 73's MDS dated [DATE], showed Resident 73's BIMS score was 12, indicating moderate cognitive impairment.
Review of Resident 73's Order Summary Report dated 3/1/25, showed the following physician's orders:
- to provide indwelling urinary catheter care with soap and warm water, rinse and pat dry every shift; and
- for indwelling urinary catheter size 16 French/10 ml, to monitor for placement and function every day shift for urinary retention.
On 4/1/25 at 0935 hours, during the initial tour of the facility, Resident 73 was observed with an indwelling urinary catheter connected to a urinary drainage bag placed at the side of the bed. The urinary drainage bag tubing was observed with sediments and cloudy urine.
On 4/2/25 at 1206 hours, an observation and concurrent interview was conducted with LVN 1. Resident 73 was observed with an indwelling urinary catheter connected to a urinary drainage bag placed at the side of the bed. The urinary drainage bag tubing was observed with sediments and cloudy urine. Resident 73 stated the indwelling urinary catheter was changed last weekend. LVN 1 verified Resident 73's urine was cloudy with a lot of sediments in the indwelling urinary catheter tubing. LVN 1 stated a cloudy urine with sediments in the urinary catheter tubing showed signs of an infection. Furthermore, LVN 1 stated when a resident had a change of condition, the licensed nurses must complete a COC assessment report, inform the physician to obtain an order, inform the resident's responsible party, initiate a care plan, monitor the resident every shift for 72 hours, and document the assessment in the resident's progress notes. LVN 1 acknowledged Resident 73's cloudy urine with sediments in the resident's urinary catheter tubing was a change in the resident's condition.
On 4/4/25 at 0955 hours, an observation, interview, and concurrent medical record review was conducted with LVN 12. Resident 73 was observed with cloudy urine and sediments in the urinary catheter tubing. LVN 12 verified the findings. LVN 12 was asked to show the COC documentation, progress notes, and care plan for Resident's 73's cloudy urine with sediments in the urinary catheter between the dates of 4/1-4/4/25. LVN 12 verified there were no COC documentation, progress notes, and care plan for Resident's 73's cloudy urine with sediments in the urinary catheter tubing between the dates of 4/1-4/4/25, in the resident's EHR.
On 4/4/25 at 1029 hours, a follow-up interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked to show the COC documentation, progress notes, and care plan for Resident's 73's cloudy urine with sediments in the urinary catheter tubing between the dates of 4/1-4/4/25. LVN 1 verified there was no COC documentation, progress notes and care plan initiated or completed in Resident 73's EHR. LVN 1 stated he reported the resident's cloudy urine with sediments (change of condition) to RN 2 and LVN 9. LVN 1 stated RN 2 and LVN 9 were supposed to follow up and complete the documentation.
On 4/4/25 at 1036 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked regarding the facility expectation when a resident had a change of condition. RN 2 stated the licensed nurses must complete the COC documentation, inform the physician, and initiate a care plan in the resident's EHR. RN 2 stated she was not aware of Resident's 73's cloudy urine with sediments in the urinary catheter tubing. RN 2 verified there was no COC documentation, progress notes, and care plan for Resident's 73's cloudy urine with sediments in the urinary catheter tubing between the dates of 4/1-4/4/25, in the resident's EHR.
On 4/7/25 at 1420 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for two of two final sampled residents (Residents 3 and 30) reviewed for enteral feeding.
* The facility failed to ensure the intake and output were monitored for Resident 30 who was receiving an enteral feeding.
* The facility failed to ensure Resident 3's enteral feeding formula was changed within 24 hours and label the resident's enteral feeding water bag with the date and time the bag was prepared.
These failures posed the risk for developing complications related to enteral feeding and GT.
Findings:
Review of the facility's P&P titled Intake, Measuring and Recording revised 5/2024 showed the following:
- The purpose of this procedure is to accurately determine the amount of liquid the resident consumes in a 24 hour period;
- At the end of the shift, the facility staff should total the amounts of all liquids the resident consumed;
- Record all the fluid intake on the intake and output record in cubic centimeters;
- Post an intake and output record form in the resident's room; and
- The following should be recorder in the resident's medical record, per facility guidelines: the date and time the resident's fluid intake was measured and recorded, the name and title of the individual who measured and recorded the resident's fluid intake, the amount of liquid consumed, the type of liquid consumed, if the resident refused the treatment, the reason why and the intervention taken, and the signature and title of the person recording the data.
1. On 4/1/25 at 1204 hours, during the initial tour of the facility, Resident 30 was observed awake and sitting on the bed. Family Member 5 was observed with Resident 30 in the room. An enteral feeding pump was observed on at 50 ml/hr. Family Member 5 stated Resident 30 had a GT and had been receiving an enteral feeding because the resident was not eating well in the past due to an illness. Family Member 5 stated Resident 30 could now eat a meal by mouth and at times would request the enteral feeding to stop so he could walk around.
Medical record review for Resident 30 was initiated on 4/1/25. Resident 30 was admitted to the facility on [DATE].
Review of Resident 30's H&P examination dated 2/23/25, showed Resident 30 had the capacity to understand and make decisions and a medical history of dysphagia (difficulty swallowing).
Review of Resident 30's Order Summary Report showed a physician's order dated 2/22/25, to administer Glucerna (enteral feeding formula) at 50 ml/hr for 20 hours to provide 1000 ml/1380 kcal via GT; to start the infusion at 1200 hours, off at 0800 hours, or until the total volume was completed.
Review of Resident 30's plan of care initiated on 2/26/25, showed a care plan problem addressing Resident 30's enteral nutrition and GT use related to aspiration pneumonia. The interventions included to monitor the intake and output per the facility protocol.
Further review of Resident 30's medical record did not show documented evidence Resident 30's intake and output was being monitored.
On 4/3/25 at 1410 hours, an interview and concurrent medical record review for Resident 30 was conducted with LVN 5. LVN 5 stated the facility did not usually record the intake and output for the residents who were on a tube feeding all throughout the residents' stay in the facility. LVN 5 stated the facility staff would monitor the intake and output only for a certain period. LVN 5 stated she could not recall and would have to verify with the DON when LVN 5 was asked what the intake and output monitoring protocol of the facility was. LVN 5 stated the care plan interventions should be implemented and followed. LVN 5 verified there was no documentation in Resident 30's medical record which showed the intake and output for Resident 30 was being monitored.
On 4/3/25 at 1522 hours, an interview and concurrent medical record review for Resident 30 was conducted with the DON. The DON stated the facility's protocol for monitoring the intake and output was to monitor the residents who were admitted with a diet and eating by mouth for three days, and the residents who were admitted with the enteral feeding for 30 days. The DON stated it was important to monitor the intake and output to evaluate the nutritional intake of the resident. The DON stated monitoring the resident's intake would determine if the resident was able to tolerate the enteral feeding, and if the enteral feeding was stopped due to unusual occurrences. The DON further stated the care plan should always be implemented and followed. The DON verified Resident 30's medical record did not show documented evidence Resident 30 was being monitored for the intake and output related to the enteral feeding.
2. Review of the facility's P&P titled Enteral Feedings - Safety Precautions revised 5/2024 showed enteral feedings are to be changed at least every 24 hours or as specified by the manufacturer guidelines and properly labeled with the nurse's initials, date and time the formula was prepared.
Medical record review for Resident 3 was initiated on 4/1/25. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 3's H&P examination dated 1/17/25, showed Resident 3 had no capacity to understand and make decisions.
Review of Resident 3's diagnosis information dated 9/23/22, showed Resident 3 had a medical history of dysphagia.
On 4/1/25 at 1002 hours, Resident 3 was observed lying in bed. An enteral feeding pump was observed with Jevity 1.2 (enteral formula) bottle hanging from the feeding pump pole. The enteral formula bottle was labeled 3/28 for the start date but without the start time or the licensed nurse's initials. The enteral feeding water bag was observed without the date and time the bag was prepared.
Review of Resident 3's Order Summary Report showed the following orders:
- dated 1/15/25, to administer Jevity 1.2 via feeding pump at 30 ml per hour for 20 hours per day, to provide a total volume of 1200 ml.
- dated 1/18/25, to administer water flush via feeding pump at 30 ml per hour for 20 hours per day from 1200-0800 hours.
On 4/1/25 at 1010 hours, an interview and concurrent observation was conducted with LVN 6. Resident 3's enteral feeding formula was observed labeled 3/28 and without a start time or the licensed nurse's initials. The enteral feeding water bag was not labeled with the date and time when the bag was prepared. LVN 6 verified the findings and stated the enteral feeding formula and the water bag should be changed every 24 hours when starting the enteral feeding at 1200 hours.
On 4/3/25 at 1327 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to to provide the necessary...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to to provide the necessary care and services to maintain the IV site accesses for two of 28 final sampled residents (Residents 67 and 667) and two nonsampled residents (Residents 366 and 916) as evidenced by:
* The facility failed to ensure the PICC line baseline external catheter length and arm circumference measurements were obtained and documented for Residents 667 and 916.
* The facility failed to ensure the arm circumference and external catheter length were measured on admission and during the midline dressing change for Resident 366's midline line use.
* Residents 67's PIV site was not labeled with the date, time, and licensed nurse's initials. In addition, the facility failed to ensure a physician's order was obtained for the use of the PIV.
These failures had the potential to delay the identification of intravenous catheter related complications for the residents.
Findings:
According to the National Library of Medicine, assessment of the PICC line included measuring external length of PICC and using this for future measurement comparison. Additionally, arm circumference is measured each shift and results compared to previous readings. Furthermore when doing dressing changes, the dressing is to be labeled with the date, time, and initials of staff doing dressing change.
On 4/1/25 at 0830 hours, an observation and concurrent interview was conducted with Resident 667. Resident 667 was observed with a PICC to her left upper extremity. Resident 667 stated the PICC line was used to administer her antibiotic medication.
Medical record review for Resident 667 was initiated on 4/1/25. Resident 667 was admitted to the facility on [DATE].
Review of Resident 667's H&P examination dated 3/29/25, showed Resident 667's diagnoses included status post tooth infection and brain abscess (build up of pus in the brain).
On 4/1/25 at 1604 hours, an observation, interview, and concurrent medical record review was conducted with RN 1. When asked to show the date for Resident 667's PICC line dressing, Resident 667's left arm was observed with blood surrounding the PICC line. Resident 667 stated she had pain on her left shoulder and pain when raising her left arm. Resident 667 stated she noticed blood on the site of her PICC line after showering on 4/1/25. When asked about the baseline external catheter length and arm circumference measurements for Resident 667's PICC line, RN 1 stated Resident 667's medical record did not include the baseline measurements as mentioned above.
3. Medical record review for Resident 916 was initiated on 4/3/25. Resident 916 was admitted to the facility on [DATE].
On 4/1/25 at 0858 hours, Resident 916 was observed in bed. Resident 916 stated he had an infection on both feet and was on IV antibiotic. Resident 916 stated he had a PICC line on the right upper arm and showed his PICC line with the transparent dressing. The PICC line dressing was observed with a label dated 3/31/25.
Review of Resident 916's Order Summary Report dated 4/3/25, failed to show a physician's order to measure the PICC line external catheter length with each dressing change and as needed and to document the arm circumference in centimeters upon admission to the facility.
Further review of Resident 916's medical record failed to show the baseline measurements for the length of the external catheter and arm circumference above the insertion site were obtained upon admission to the facility.
Review of Resident 916's plan of care failed to show a care plan was formulated to address Resident 916's use of the PICC line.
Review of Resident 916's IV Administration Record for March 2025 failed to show documented evidence the arm circumference measurement was documented upon Resident 916's admission to the facility.
On 4/1/25 at 1602 hours, an observation and concurrent interview for Resident 916 was conducted with RN 1. RN 1 verified Resident 916 was on IV antibiotic medication for an infection to the lower leg. RN 1 was asked about the baseline measurements of Resident 916's PICC length of the catheter and arm circumference. RN 1 verified and acknowledged the baseline measurements of Resident 916's PICC line length of the catheter and arm circumference were not obtained upon admission of Resident 916 to the facility.
On 4/3/25 at 1331 hours, an interview and concurrent medical record review for Resident 916 was conducted with the ADON. The ADON stated upon admission to the facility for the resident who had a PICC line, the RN supervisor was responsible for the assessment, care and maintenance of the PICC line. The ADON verified there was no baseline measurements of the length of the catheter and arm circumference obtained for Resident 916's PICC line upon admission to the facility. The ADON verified there was no care plan formulated for Resident 916's use of PICC line.
On 4/7/25 at 1012 hours, an interview and concurrent medical record review for Resident 916 was conducted with the DON. The DON was informed and verified the above findings.
2. On 4/1/25 at 0952 hours, during the initial tour of the facility, Resident 366 was observed awake and lying in the bed. Resident 366 was observed with a midline to the left upper arm. Resident 366 stated he was getting IV antibiotic medication for his knee infection. Resident 366's midline dressing was observed dated 3/31/25.
Medical record review for Resident 366 was initiated on 4/1/25. Resident 366 was admitted to the facility on [DATE].
Review of Resident 366's MDS assessment dated [DATE], showed Resident 366 was cognitively intact.
Review of Resident 366's Order Summary Report showed the following physician's orders dated 3/17/25, to measure the length of the midline external catheter on admission and with each dressing change, and to include the measurement of the arm circumference for midline device every seven days (every Sunday at night shift) and as needed.
Review of Resident 366's IV MAR for March 2025 showed the documentation of the midline dressing changed on 3/23/25; however, there was no documentation of the measurement of the arm circumference and the length of the midline external catheter. The section to document the measurement on the IV MAR showed, NA. Further review of the IV MAR did not show the documentation of the midline dressing change on 3/31/25, measurement of the arm circumference, and length of the midline external catheter.
Further review of Resident 366's medical record failed to show any documentation of the measurement of the arm circumference and measurement of the length of the midline external catheter upon admission to the facility.
On 4/1/25 at 1606 hours, an interview and concurrent medical record review for Resident 366 was conducted with RN 1. RN 1 verified the midline dressing for Resident 366 was dated 3/31/25, and the midline dressing was previously changed on 3/23/25. RN 1 stated the baseline measurement of the arm circumference should be assessed upon admission to the facility and during the midline dressing change because if the arm became swollen it could indicate complications or infection. RN 1 stated measuring the length of the midline external catheter could provide a reference every time it was measured during the midline dressing change to check if the catheter placement was still intact or maintained, or if it was dislodged. RN 1 verified there was no documentation in Resident 366's medical record to show the arm circumference was measured upon admission to the facility and during the midline dressing change. RN 1 also verified there was no documentation to show the length of the midline external catheter was measured. RN 1 stated the NAdocumented on the IV MAR could mean not applicable. RN 1 further stated she was the one who did the midline dressing change for Resident 366 on 3/31/25, but needed to document her assessment for the midline. When RN 1 was asked what the measurements of the arm circumference and length of the midline external catheter for Resident 366 were, RN 1 stated she would have to check her notes.
On 4/4/25 at 1630 hours, the DON was informed and acknowledged the above findings.
4. Review of the facility's P&P titled IV undated, showed the following:
- Verify the physician's order; and
- Document when the treatment was initiated.
Medical record review for Resident 67 was initiated on 4/1/25. Resident 67 was admitted to the facility on [DATE].
Review of Resident 67's MDS assessment dated [DATE], showed Resident 67's BIMS score was 12, indicating moderate cognitive impairment.
Review of Resident 67's Order Summary Report dated 3/1/25, did not show a physician's order to start a peripheral intravenous access.
On 4/1/25 at 1045 hours, during the initial tour of the facility, Resident 67 was observed awake, alert and sitting up in the wheelchair. Resident 67 was observed with the right wrist PIV not labeled with the date, time, and licensed nurse's initials. Resident 67 stated the PIV access was inserted by the facility's licensed nurse two to three days ago.
On 4/1/25 at 1122 hours, an observation and concurrent interview was conducted with LVN 6. Resident 67 was observed with the right wrist PIV not labeled with the date, time, and licensed nurse's initials. LVN 6 verified the above findings. LVN 6 stated Resident 67 did not have a physician's order for the use of the PIV.
On 4/4/25 at 1316 hours, an interview was conducted with RN 2. RN 2 was asked what must be obtained prior to starting a PIV for the resident. RN 2 stated there must be a physician's order to start the PIV. RN 2 stated after the PIV was started, it must be labeled with the date, time, and licensed nurse's initials to keep track when the PIV was placed and monitor for any signs of infection. Furthermore, RN 2 verified Resident 67 did not have a physician's order for the PIV and stated the facility's IV order set in the EHR did not include the physician's order for the PIV insertion.
On 4/7/25 at 1420 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 04/1/25 at 0945 hours, Resident 21 was observed in bed with his oxygen tubing on the floor.
Medical record review for Resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 04/1/25 at 0945 hours, Resident 21 was observed in bed with his oxygen tubing on the floor.
Medical record review for Resident 21 was initiated on 4/1/25. Resident 21 was admitted to the facility on [DATE].
Review of Resident 21's H&P examination dated 1/11/25, showed Resident 21's diagnoses included post status hospital acquired pneumonia.
Review of Resident 21's Order Summary Report for April 2025 showed a physician's order dated 3/12/25, to administer oxygen at three liters per minute continuously via nasal cannula.
On 04/1/25 at 1607 hours, an observation and concurrent interview was conducted with the IP in Resident 21's room. Resident 21 was observed with his oxygen tubing touching the floor. The IP verified the findings.
3. Review of the facility's P&P titled CPAP/BiPAP Support dated 5/2024 showed specific cleaning instruction guidelines are obtained from the manufacturer of the PAP device. The components of the machine such as the masks, nasal pillows, tubing and headgear should be cleaned with a mild detergent daily and allow to airdry.
On 4/1/25 at 0810 hours, and 4/3/25 at 0834 hours, an observation and concurrent interview for Resident 101 was conducted with CNA 8. Resident 101 was observed in bed and with a CPAP machine at the bedside drawer. The CPAP's mask was observed on top of the drawer and the tubing was placed inside the clear plastic bag. CNA 8 verified the CPAP machine (ResMed Air-curve 10) at Resident 101's bedside drawer.
According to the ResMed Air-curve 10 (CPAP machine) user guide, under the Caring for the Device section, showed to regularly clean the tubing assembly, water tub, and mask to prevent the growth of the germs that can adversely affect the health. Clean the device weekly as directed.
Medical record review for Resident 101 was initiated on 4/3/25. Resident 101 was admitted to the facility on [DATE].
Review of Resident 101's Order Summary Report dated 4/3/25, showed there was no physician's order obtained to clean the CPAP device weekly as directed by the user's guide.
Review of Resident 101's plan of care failed to show documented evidence a care plan was developed to address Resident 101's use of the CPAP machine.
On 4/3/25 at 1352 hours, an interview and concurrent medical record review for Resident 101 was conducted with LVN 3. LVN 3 verified there was no physician's order for the maintenance of the CPAP machine for Resident 101. LVN 3 was asked for the copy of the user guide of the CPAP machine for Resident 101. LVN 3 acknowledged there were no copies available of the user guide for the CPAP machine.
On 4/7/25 at 1012 hours, an interview and concurrent medical record review for Resident 101 was conducted with the DON. The DON was asked about the CPAP machine's care and maintenance. The DON stated the care and maintenance for the CPAP machine should be done per the machine user guide from the manufacturer. The DON was informed and verified the above findings.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of two final sampled residents (Residents 21 and 30) and two nonsampled residents (Residents 7 and 101) reviewed for respiratory care were provided with the appropriate respiratory care and services when:
* The facility failed to ensure Residents 7 and 30 were receiving the oxygen as per the physician's order and the nasal cannula tubing was stored in a sanitary manner.
* The facility failed to ensure Resident 101's CPAP machine was cleaned as per the manufacturer's user guidelines.
* The facility failed to ensure Resident 21's oxygen tubing was not on the floor.
These failures had the potential to affect the respiratory health and well-being of these residents in the facility.
Findings:
Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the staff should verify there is a physician's order for oxygen administration and review the physician's orders or facility protocol for oxygen administration.
Review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection revised 5/2024 showed under the Infection Control Considerations Related to Oxygen Administration, to change the oxygen cannula and tubing every seven days, or per the manufacturer's guidelines as needed and to keep the oxygen cannula and tubing used as needed in a plastic bag when not in use.
1. On 4/1/25 at 1013 hours, during the initial tour of the facility, Resident 7 was observed awake and sitting in a wheelchair outside the room. The nasal cannula was observed on the resident's bed and not stored in a plastic bag/container. The oxygen concentrator was observed on at two liters per minute. Resident 7 stated he used the oxygen on and off. Resident 7 stated he would put the oxygen tubing back on when he went back to bed.
Medical record review for Resident 7 was initiated on 4/1/25. Resident 7 was admitted to the facility on [DATE].
Review of Resident 7's H&P examination dated 2/18/25, showed Resident 7 had the capacity to understand and make decisions. The H&P examination also showed Resident 7 had history of COPD.
Review of Resident 7's plan of care initiated on 2/27/25, showed a care plan problem addressing Resident 7's use of oxygen continuously related to COPD. The interventions included to administer oxygen at two liters per minute via nasal cannula continuously.
Review of Resident 7's Order Summary Report showed a physician's order dated 3/10/25, to administer the oxygen at two liters per minute via nasal cannula continuously every shift.
On 4/1/25 at 1025 hours, an observation, interview, and concurrent medical record review for Resident 7 was conducted with LVN 8. LVN 8 verified Resident 7 was not wearing the nasal cannula. LVN 8 verified Resident 7 had a physician's order to administer the oxygen at two liters per minute via nasal cannula continuously. LVN 8 was observed checking the resident's oxygen saturation level. LVN 8 stated Resident 7's oxygen saturation level was 93%. LVN 8 stated the licensed nurses and RT would communicate regarding the resident's use of oxygen and discussed the ongoing need for the oxygen. LVN 8 stated either the licensed nurse or RT could communicate with the physician regarding the resident's need for continuous oxygen, to titrate the oxygen according to the need of the resident, or to change the oxygen use to as needed. LVN 8 further stated the nasal cannula or oxygen tubing should be placed in a plastic bag when not in use to prevent contamination. LVN 8 was observed placing the nasal cannula tubing back inside the plastic bag hanging in Resident 7's drawer cabinet.
2. On 4/2/25 at 1020 hours, an observation was conducted with Resident 30. Resident 30 was observed lying in the bed with his eyes closed. The oxygen concentrator was observed on at two liters per minute. The nasal cannula tubing was observed wrapped around the elevated right bed rail.
Medical record review for Resident 30 was initiated on 4/2/25. Resident 30 was admitted to the facility on [DATE].
Review of Resident 30's H&P examination dated 2/23/25, showed Resident 30 had the capacity to understand and make decisions.
Review of Resident 30's Order Summary Report showed a physician's order dated 3/14/25, to administer oxygen at two liters per minute to keep the oxygen saturation level greater than 92% every shift.
On 4/2/25 at 1226 hours, a follow-up observation and concurrent interview was conducted with Resident 30. Family Member 1 was observed at the bedside. The nasal cannula tubing was observed wrapped around the elevated right bed rail and the oxygen concentrator was observed on at two liters per minute. Family Member 1 stated Resident 30 had not been using the oxygen regularly since 3/29/25. Family Member 1 stated Resident 30 would use the oxygen when the resident had shortness of breath.
On 4/2/25 at 1232 hours, an interview and concurrent medical record review for Resident 30 was conducted with RT 1. RT 1 verified the oxygen order for Resident 30 was continuous and the nasal cannula tubing was not stored in a sanitary manner. RT 1 stated the RT had followed up with the residents who were on oxygen therapy. RT 1 stated the RT would check the residents with oxygen therapy during the shift and touch base with the licensed nurses regarding the respiratory status of the residents. RT 1 stated Resident 30's oxygen saturation level was greater than 92% on room air. RT 1 stated the RT or licensed nurses could notify the physician if the oxygen was not being used because the resident's oxygen saturation level was above 92% on room air and the physician could change the oxygen order to as needed or titrate the oxygen per the resident's need. RT 1 verified there was no documentation showing the RT or licensed nurse reported to the physician regarding the respiratory status of Resident 30. RT 1 further stated the nasal cannula tubing should be placed in a plastic bag for infection prevention measure to prevent contamination.
On 4/4/25 at 1630 hours, the DON was informed and acknowledged the above findings for Residents 7 and 30.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain manageme...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for one of two final sampled residents (Resident 111) reviewed for pain management.
* The facility failed to accurately document the monitoring of pain for Resident 111 and administer the pain medication according to the physician's order. In addition, the facility failed to ensure the non-pharmacological interventions were provided to Resident 111 prior to the administration of the pain medication. These failures had the potential to put Resident 111 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.
Findings:
Review of the facility's P&P titled Pain Assessment and Management revised 5/2024 showed the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on the professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Pharmacological interventions may be prescribed to manage pain, however they do not usually address the cause of pain and can have adverse effects on the resident (e.g., drowsiness, increased risk of falling; loss of appetite). When opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential side effects.
Medical record review for Resident 111 was initiated on 4/1/25. Resident 111 was admitted to the facility on [DATE].
Review of Resident 111's Order Summary Report for April 2025 showed the following physician's orders:
- dated 2/12/25, to monitor Resident 111's level of pain every shift, using the 0-10 pain scale as follows: 0= no pain, 1-4= mild pain, 5-6= moderate pain, and 7-10= severe pain,
- dated 2/12/25, to implement the non-pharmacological interventions for pain prior to administering the pain medication; and to document 1. Back rub; 2. Repositioning; 3. Warm drink; 4. TV/Music; 5. Ice pack; 6. None.
- dated 2/12/25, to administer oxycodone (narcotic opioid medication) 5 mg one tablet by mouth every six hours a needed for moderate to severe pain, pain levels of 6-10.
Review of Resident 111's MAR for March 2025 showed Resident 111 was administered oxycodone 5 mg one tablet by mouth when the pain level was not within the ordered pain level parameters (pain 6-10) on the following dates and times:
- dated 3/3/25 at 2007 hours, for a pain level of 0.
- dated 3/17/25 at 1530 hours, for a pain level of 0; and at 2138 hours, for a pain level of 0.
- dated 3/24/25 at 1525 hours, for a pain level of 0; and at 2120 hours, for a pain level of 0.
Review of Resident 111's MAR for March and April 2025 showed Resident 111 was administered oxycodone 5 mg one tablet by mouth every six hours a needed for moderate to severe pain (pain levels of 6-10) on the following dates and times:
- dated 3/8/25 at 0833 hours, for a pain level of 7.
- dated 3/15/25 at 0949 hours, for a pain level of 6.
- dated 4/3/25 at 1500 hours, for a pain level of 8.
However, review of Resident 111's MAR for March 2025 showed the licensed nurses documented Resident 111's pain level as 0 for no pain for the following dates and shifts:
- for the day shifts (from 0700 to 1500 hours) on 3/8, 3/15, and 3/24/25.
- for the evening shifts (from 1500 to 2300 hours) on 3/3, 3/17, and 3/24/25.
Further review of Resident 111's MAR for March and April 2025 showed the licensed nurses documented the non-pharmacological pain interventions (NPI) for the following dates and shifts:
- dated 3/3/25 for the evening shift, the NPI was documented as none,
- dated 3/15/25 for the day shift, the NPI was documented as none,
- dated 3/24/25 for the evening shift, the NPI was documented as none, and
- dated 4/3/25, for the day shift, the NPI was documented as none.
Review of Resident 111's plan of care showed a care plan problem dated 2/12/25, addressing Resident 111's use of the oxycodone pain medication. The interventions showed to administer the medications as ordered.
On 4/7/25 at 1005 hours, an interview and concurrent medical record review for Resident 111 was conducted with LVN 6. LVN 6 stated for the residents who reported pain, the non-pharmacological pain interventions would be implemented and documented prior to the administration of the pain medications. LVN 6 stated if the non-pharmacological pain interventions were effective, then the pain medication would not be needed. LVN 6 further stated if the non-pharmacological interventions were ineffective, then the pain medication would be administered as per the physician's order and within the ordered parameters. LVN 6 reviewed Resident 111's medical record and verified the above findings. LVN 6 stated if the oxycodone medication was administered, the pain level should not be documented as zero. LVN 6 further stated, if the pain medication was administered, the non-pharmacological pain intervention should not be documented as none.
On 4/7/25 at 1403 hours, an interview and concurrent medical record review for Resident 111 was conducted with the DON. The DON stated prior to the administration of the pain medication, the licensed nurse was expected to assess the resident's level of pain, implement the non-pharmacological pain interventions and document the NPIs implemented. The DON further stated if the pain medication was administered to the resident, then the NPI should not be documented as none. Additionally, the DON stated she expected the licensed nurses to accurately document the resident's pain each shift. The DON stated if the pain medication was administered to the resident during the shift, then there should be a pain level documented for the monitoring of pain, for that shift in the MAR. The DON stated if the resident reported pain after the licensed nurse documented no pain, the DON expected the licensed nurse to update the pain monitoring for that shift in the MAR or the progress notes, to accurately reflect the resident's pain monitoring. The DON reviewed Resident 111's medical record and verified the above findings.
On 4/7/25 at 1430 hours, an interview was conducted with the DON. The DON was informed and acknowledged above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care was provided for two of 28 final sampled residents (Residents 70 and 88) reviewed for dialysis services.
* The facility failed to ensure the dialysis communication records were accurately completed for Resident 70.
* The facility failed to ensure the emergency dialysis kit was kept at Resident 88's bedside. In addition, the facility failed to ensure the licensed nurses assessed and documented Resident 88's dialysis access, and covered Resident 88's dialysis access site with a transparent dressing.
These failures had the potential for the residents to experience medical complications.
Findings:
1. Review of the facility's P&P titled Care of a Resident with End-Stage Renal Disease dated 2001 showed the residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.
Medical record review for Resident 70 was initiated on 4/1/25. Resident 70 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 70's H&P examination dated 5/10/24, showed Resident 70 had no capacity to understand and make decisions.
Review of Resident 70's admission Record showed Resident 70 had a diagnosis of ESRD and was dependent on renal dialysis.
Review of Resident 70's Order Summary Report for April 2025 showed a physician's order dated 3/31/25, for hemodialysis every Monday, Wednesday, and Friday at the dialysis facility.
Review of Resident 70's Dialysis Communication Record showed multiple blank entries as follows:
- dated 12/16, 12/20, 12/29/24, 1/3, 1/6, 1/24, 2/24, 3/3, 3/24 and 3/26/25, for the dialysis access site assessment.
On 4/3/25 at 1340 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated the dialysis communication records should have been completely filled out accordingly prior to going to the dialysis center.
On 4/7/25 at 1418 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the dialysis communication records should have been filled out completely as it served as a communication tool between the dialysis center and the facility.
2. Review of the facility's P&P titled Hemodialysis Catheters- Access and Care of, revised 2/2024 showed the central catheters for hemodialysis are generally inserted in the neck, chest, or groin area. This is not the preferred site for long-term placement. There is more risk of clotting and infection than with either fistulas (surgical connection of an artery and a vein) or grafts (the use of a synthetic or animal-derived tubing to connect the artery and vein). Under the section Care of Central Dialysis Catheters, showed the central catheter site must be kept clean and dry at all times. Those caring for the catheter site must wear a mask and gloves when doing so. The dressing changes, if ordered, should be done using sterile techniques. The licensed nurse should document in the resident's medical record every shift as follows:
1. Location of catheter.
2. Condition of the dressing (interventions if needed).
Medical record review for Resident 88 was initiated on 4/1/25. Resident 88 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 88's H&P examination dated 2/3/25, showed Resident 88 had no capacity to make medical decisions.
Review of Resident 88's MDS assessment dated [DATE], showed Resident 88 had moderately impaired cognition. The MDS also showed Resident 88 had a diagnosis of end-stage renal disease (loss of kidney function) and was dependent on renal dialysis and receiving dialysis treatment while a resident at the facility.
Review of Resident 88's Order Summary Report showed the following physician's orders:
- dated 4/1/25, a discontinued order for the dialysis schedule every Fridays at 1530 hours. Chair time: three hours, from 1545 to 1845 hours.
- dated 4/1/25, for the dialysis center to provide the dialysis catheter access site care including changing the caps.
- dated 4/1/25, for the dialysis emergency kit to be maintained at bedside every shift.
- dated 4/4/25, to immediately apply pressure to stop the bleeding, if bleeding was noted from the dialysis access site. If the bleeding did not subside, call the physician and activate EMS services.
Review of Resident 88's progress notes showed a Nurse's Note dated on 3/31/25 at 1304 hours, showing the licensed nurse receiving a call from Dialysis Center A to inform the facility that Resident 88 did not need to show up for dialysis on 3/31/25, and the resident no longer needed dialysis until further order.
Review of Resident 88's MAR and TAR for April 2025 failed to show documentation Resident 88's right upper chest dialysis catheter was assessed by the licensed nurses.
Review of Resident 88's plan of care failed to show a care plan problem to address the care of Resident 88's right upper chest dialysis catheter.
On 4/7/25 at 0959 hours, an interview and concurrent observation was conducted with LVN 6. LVN 6 stated Resident 88 was previously receiving dialysis treatments but recently no longer required the dialysis treatments. When asked about Resident 88's dialysis access, LVN 6 inspected Resident 88 and stated Resident 88 still had a dialysis access located in his right upper chest. When asked, LVN 6 stated Resident 88 should have an emergency dialysis kit at the bedside. When asked to show Resident 88's emergency dialysis kit, LVN 6 was observed checking Resident 88's closet and bedside drawer and LVN 6 stated Resident 88 did not have an emergency dialysis kit at his bedside. LVN 6 further stated even though, Resident 88 was no longer receiving the dialysis treatments, and he should still have an emergency dialysis kit at the bedside, in the event there was an emergency.
On 4/7/25 at 1403 hours, an interview was conducted with the DON. The DON stated for any resident with a dialysis access, even if the resident was not currently receiving the dialysis treatment, there should be an emergency dialysis kit at the bedside, readily available.
On 4/7/25 at 1525 hours, a follow-up interview, observation, and concurrent medical record review for Resident 88 was conducted with the DON. The DON stated the dressing on a resident's dialysis access was applied by the dialysis center after the dialysis treatment. The DON stated for a resident who was no longer receiving dialysis treatments, the licensed nurses were responsible for assessing the resident's dialysis access, checking for any bleeding or signs and symptoms of infection and documenting the assessment in the MAR, every shift. Additionally, the DON stated for the resident who was no longer receiving the dialysis treatment but still had a dialysis catheter, the facility staff was responsible for changing the dressings for the dialysis access site and covering the dialysis access with a transparent dressing. The DON reviewed Resident 88's medical record and verified the above findings. When asked when the last dressing change was provided for Resident 88's right chest dialysis access, the DON stated she was unable to find the documentation. A concurrent observation and interview was conducted at Resident 88's bedside. Resident 88 was observed with the right chest permacath (type of central catheter); however, a transparent dressing was not observed covering the permacath. The DON verified the above findings and stated there should be a transparent dressing covering Resident 88's dialysis permacath on the right upper chest.
On 4/7/25 at 1535 hours, the DON was informed and acknowledged the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure dementia care int...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure dementia care interventions were being implemented for one of five sampled residents (Resident 105) reviewed for dementia care. This failure had the potential for Resident 105 to not receive the appropriate treatment and services needed for her dementia.
Findings:
Review of the facility's P&P titled Dementia - Clinical Protocol revised 11/2018 showed the following:
- The staff and physician will evaluate individuals with new or worsening cognitive impairment and behavior and differentiate dementia from other causes;
- The staff and physician will review current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual's condition, related complications, and functional abilities and impairments;
- The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise;
- Progressive or persistent worsening of symptoms and increased need of staff will be reported to the IDT; and
- The staff will monitor the individual with dementia for changes and decline in function and will report theses findings to the physician.
On 4/1/23 at 1147 hours, during the initial tour of the facility, Resident 105 was observed lying and sleeping in the bed.
Medical record review for Resident 105 was initiated on 4/1/25. Resident 105 was admitted to the facility on [DATE].
Review of Resident 105's H&P examination dated 12/12/24, showed Resident 105 had no capacity to make medical decisions and had a medical history of dementia.
Review of Resident 105's plan of care revised on 12/19/24, showed a care plan problem addressing Resident 105's risk for altered mood and little interest or pleasure in doing things related to dementia. The interventions included to monitor/record/report to the physician as needed the resident's acute episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate, and change in psychomotor skills; and to monitor/record/report to the physician as needed mood patterns signs and symptoms of depression (mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and sad mood as per facility behavior monitoring protocols.
Review of Resident 105's MDS assessment dated [DATE], showed Resident 105 had severe cognitive impairment and was dependent for most of her ADL care.
Further review of Resident 105's medical record did not show documented evidence Resident 105 was being observed/monitored for the signs and symptoms of altered mood related to her dementia.
On 4/3/25 at 1000 hours, a follow-up observation and concurrent interview was conducted with Resident 105. Resident 105 was observed awake and lying in the bed. Resident 105 did not answer any questions asked and just stared off.
On 4/3/25 at 1005 hours, an interview and was conducted with CNA 4. CNA 4 stated Resident 105 knew her name and the facility, but everyday was different and Resident 105 needed reminders or reorientation from the facility staff. CNA 4 stated Resident 105 was confused, refused care, and combative at times. CNA 4 stated Resident 105 could be aggressive when being changed or cleaned but if Resident 105 was not being touched, the resident was fine. CNA 4 stated for the residents with dementia, two CNAs were needed for assisting with ADL care and the facility staff had to document their behavior and mood daily. CNA 4 was not able to show any documented behavior or mood related to dementia for Resident 105.
On 4/4/25 at 1320 hours, an interview and concurrent medical record review for Resident 105 was conducted with LVN 5. LVN 5 stated Resident 105 was oriented to herself, normally sleepy, took her medications and drank the Ensure (protein drink supplement) and would go back to sleep. LVN 5 stated Resident 105 did not really interact with the facility staff and even with her family member. LVN 5 stated Resident 105 had a behavior of being angry. LVN 5 stated the facility staff would document the mood or behavior in the MAR and if the resident was acting out, a change of condition assessment would be done, and the physician would be notified. LVN 5 verified there was no documented evidence Resident 105 was being assessed or monitored for the signs and symptoms of altered mood and little interest or pleasure in doing things related to dementia as stated in the resident's plan of care.
On 4/4/25 at 1446 hours, an interview and concurrent medical record review for Resident 105 was conducted with the DON. The DON stated if there was a monitoring for certain behaviors related to a disease like dementia in the plan of care, the monitoring should be initiated and implemented. The DON stated it was important to monitor the behavior manifested to identify if there was progression in the disease process and the facility staff and physician could intervene and manage the resident's care properly. The DON verified there was no documentation in Resident 105's medical record showing the resident was being assessed or monitored for the signs and symptoms of altered mood and little interest or pleasure in doing things related to dementia as stated in the resident's plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services as per the facility's P&P for one of 28 final sampled Resident (Resident 65) and one nonsampled resident (Resident 55).
* The facility failed to ensure the administration of the controlled medication for Residents 55 and 65 was documented on the EMAR. This failure had the potential for the medications to be administered in error and opportunities for drug diversion or drug misuse.
Findings:
Review of the facility's P&P titled Controlled Substances revised 11/2022 showed the system of dispensing of controlled substances includes the following: Records of personnel access and usage; medication administration records.
Review of the facility's P&P titled Medication Administration revised 5/2024 showed individual administering the medications initials the resident's MAR on the appropriate line after giving each medication. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered; the dosage, the route of administration; the signature and title of the person administering the drug.
1. Medical record review for Resident 65 was initiated on 4/1/25. Resident 65 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 65's H&P examination dated 5/9/24, showed Resident 65 had the capacity to understand and make decisions.
Review of Resident 65's Order Summary Report dated 4/1/25, showed a physician's order dated 3/23/25, to administer oxycodone-acetaminophen (controlled pain medication) 5-325 mg one tablet by mouth every six hours as needed for moderate pain (pain level of 4-6) to severe pain (pain level of 7-10), using the 0-10 pain scale; zero meaning no pain and 10 meaning the worst pain.
Review Resident 65's Medication Count Sheet showed the oxycodone-acetaminophen 5-325 mg medication was dispensed and signed out on 3/31/25 at 1830 hours.
Review of Resident 65's March 2025 MAR failed to show the documentation of the administration for the oxycodone-acetaminophen 5-325 mg medication on 3/31/25 at 1830 hours.
On 4/1/25 at 1145 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings.
2. Medical record review for Resident 55 was initiated on 4/1/25. Resident 55 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 55's H&P examination dated 12/31/24, showed Resident 55 was unable to make decisions.
Review of Resident 55's Order Summary Report dated 4/1/25, showed a physician's order dated 3/21/25, to administer lorazepam 0.5 mg one tablet by mouth every four hours as needed for anxiety manifested by verbalization of feeling anxious for 14 days.
Review Resident 55's Medication Count Sheet showed the lorazepam 0.5 mg tablet medication was dispensed and signed out on 3/31/25 at 2340 hours.
Review of Resident 55's March 2025 MAR failed to show the documentation of the administration for the lorazepam 0.5 mg medication on 3/31/25 at 2340 hours.
On 4/1/25 at 1300 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings
On 4/2/25 at 1453 hours, the DON was informed and verified the above findings. The DON stated the licensed nurse needed to document on the MAR when the medication was administered to the resident to ensure the medication administered was accounted for.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 42) reviewed for unnecessary medication was free from unnecessary medications. The facility failed to adhere to Resident 42's blood pressure parameters prescribed by the physician for three medications: amlodipine (blood pressure medication), spironolactone (diuretic medication), and ethacrynic acid (diuretic medication). This failure had the potential for Resident 42 to receive unnecessary medications and to experience adverse effects.
Findings:
Review of the facility's P&P titled Administering Medications revised 5/2024 showed medications are administered in accordance with prescribed orders.
Medical record review for Resident 42 was initiated on 4/3/25. Resident 42 was admitted to the facility on [DATE], and readmitted [DATE].
Review of Resident 42's Order Summary Report showed the following physician's orders:
- dated 12/21/24, to administer one amlodipine 5 mg tablet by mouth one time a day for hypertension (high blood pressure). The physician's order showed to hold the amlodipine if the systolic blood pressure less than 115 mmHg or if the heart rate less than 56 bpm.
- dated 2/23/25, to administer two ethacrynic acid 25 mg tablets by mouth two times a day for congestive heart failure. The physician's order showed to hold the ethacrynic acid if the systolic blood pressure less than 110 mmHg or if the heart rate less than 60 bpm.
- dated 2/23/25, to administer one spironolactone 25 mg tablet by mouth two times a day for congestive heart failure. The physician's order showed to hold the ethacrynic acid if the systolic blood pressure less than 110 mmHg or if the heart rate less than 60 bpm.
Review of Resident 42's H&P examination dated 2/24/25, showed Resident 42 had the capacity to understand and make decisions.
Review of Resident 42's MAR for January 2025 showed Resident 42 was administered the amlodipine medication when Resident 42's blood pressure was below the parameters prescribed by the physician on 1/4/25 at 0900 hours. Resident 42's systolic blood pressure was 113 mmHg.
Review of Resident 42's MAR for March 2025 showed Resident 42 was administered the ethacrynic acid and spironolactone medications when Resident 42's blood pressure was below the parameters prescribed by the physician on 3/30/25 at 1700 hours. Resident 42's systolic blood pressure was 104 mmHg.
On 4/3/25 at 1030 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 reviewed Resident 42's medical record and verified the above findings. LVN 4 stated there was a reminder for the staff regarding the medication's parameters populated on the resident's MAR before the administration of the medications.
On 4/3/25 at 1327 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/1/23 at 1147 hours, during the initial tour of the facility, Resident 105 was observed lying in the bed.
Medical record ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/1/23 at 1147 hours, during the initial tour of the facility, Resident 105 was observed lying in the bed.
Medical record review for Resident 105 was initiated on 4/1/25. Resident 105 was admitted to the facility on [DATE].
Review of the Order Summary Report showed the following physician's orders:
- dated 12/10/24, to administer Celexa (medication for depression) 10 mg one tablet by mouth at bedtime for depression as evidenced by episodes of tearfulness.
- dated 2/9/25, to monitor Resident 105 for episodes of depression as evidenced by episodes of tearfulness every shift.
Review of Resident 105's H&P examination dated 12/12/24, showed Resident 105 had no capacity to make medical decisions and had a medical history of depression (mood disorder that causes a persistent feeling of sadness and loss of interest).
Review of Resident 105's MAR for February and March 2025 showed Resident 105 was administered the following:
- Celexa medication on 2/1, and from 2/3 to 2/28/25 at 2100 hours; and
- Celexa medication from 3/1 to 3/10/25, and 3/13 to 3/31/25 at 2100 hours.
Review of Resident 105's Psychotropic Summary Sheet failed to show documentation the behavioral symptoms of depression as manifested by episodes of tearfulness were evaluated for February 2025 to determine the potential for reducing or discontinuing the Celexa medication.
On 4/3/25 at 1005 hours, an interview was conducted with CNA 4. CNA 4 stated Resident 105 knew her name and the facility, but everyday was different and Resident 105 needed reminders or reorientation from the facility staff. CNA 4 stated Resident 105 was confused, refused care, and was combative at times. CNA 4 stated Resident 105 had not had any episodes of crying or tearfulness during her shifts.
On 4/4/25 at 1320 hours, an interview and concurrent medical record review for Resident 105 was conducted with LVN 5. LVN 5 stated Resident 105 was oriented to herself, normally sleepy, took her medications and drank the Ensure (protein drink supplement), and would go back to sleep. LVN 5 stated Resident 105 did not really interact with the facility staff and even with her family member. LVN 5 stated she had not witnessed Resident 105 crying but stated Resident 105 had episodes of being angry. LVN 5 verified Resident 105's Psychotropic Summary Sheet failed to show documentation the behavioral symptoms of depression as manifested by episodes of tearfulness were evaluated for February 2025.
On 4/4/25 at 1458 hours, an interview and concurrent medical record review for Resident 105 was conducted with the DON. The DON stated the psychotropic summary for the psychotropic medication included the monitoring of the number of behavior episodes of depression manifested by the resident every shift. The DON stated the behavior summary from the previous month should be done every second or third week of the current month before the GDR meeting which happened every last week of the month. The DON stated it was necessary to complete the behavior data for the psychotropic summary because it helped to identify if there were really behaviors manifested by the resident. The DON further stated the Psychotropic Summary Sheet was a tool that the facility used for the GDR process to determine if the medication's dosage would need to be adjusted, or discontinued. The DON verified the psychotropic summary for the use of the Celexa medication was not completed for the February 2025 for Resident 105.
Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (two final sampled residents, Residents 95 and 105) reviewed for unnecessary medication were free from the unnecessary psychotropic medication.
* The facility failed to obtain Resident 95's informed consent prior to administering the Depakote (mood stabilizer) medication.
* The facility failed to evaluate the behavioral symptoms for the use of psychotropic medication for Resident 105.
These failures had the potential for the residents to experience adverse effects from the psychotropic medication.
Findings:
1. Review of the facility's P&P titled Psychoactive/Psychotropic Medication Use revised 5/2024 showed the prescribing clinician will obtain an informed consent from the resident or resident representative prior to administration of a psychotropic medication and will document the consent form in the resident's medical record. The P&P also showed monitoring of the resident receiving psychotropic medication will include evaluation of the effectiveness of the medication, as well as an assessment for possible adverse consequences. The behavioral symptoms are evaluated periodically to determine the potential for reducing or discontinuing the drug based on therapeutic goals, and any adverse effects or possible functional impairment.
Medical record review for Resident 95 was initiated on 4/1/25. Resident 95 was admitted to the facility on [DATE].
Review of Resident 95's Order Summary Report showed a physician's order dated 10/12/24, to administer Depakote 250 mg one tablet by mouth three times a day for bipolar disorder manifested by rapid mood swings.
Review of Resident 95's H&P examination dated 10/14/24, showed Resident 95 had the capacity to understand and make decisions.
Review of Resident 95's MAR for March 2025 showed Resident 95 was administered the Depakote medication from 3/1 to 3/7/25 at 0600, 1400, and 2200 hours; on 3/8/25 at 0600 and 1400 hours; and from 3/9 to 3/31/25 at 0600, 1400, and 2200 hours.
Review of Resident 95's MAR for April 2025 showed Resident 95 was administered the Depakote medication on 4/1/25 at 0600 and 1400 hours.
Review of Resident 95's medical record did not show documented evidence the informed consent was obtained from Resident 95 prior to the Depakote medication use.
On 4/2/25 at 1421 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 reviewed Resident 95's medical record and verified the above findings.
On 4/2/25 at 1443 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 95's medical record and verified the above findings.
On 4/3/25 at 1327 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 4/7/25 at 0923 hours, an observation and concurrent interview was conducted with LVN 7 after the wound care observation wa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 4/7/25 at 0923 hours, an observation and concurrent interview was conducted with LVN 7 after the wound care observation was completed. When asked, LVN 7 showed Resident 111's gentamicin ointment was missing the date when the medication was opened. LVN 7 verified the label of the medication should include the open date when the medication was opened.
On 4/7/25 at 1301 hours, an observation and concurrent interview was conducted with DON. The DON stated if a medication was opened, the label should include the open date. The DON verified Resident 111's gentamicin ointment medication label did not have an open date.
4. Medical record review for Resident 44 was initiated on 4/7/25. Resident 44 was readmitted to the facility on [DATE].
Review of Resident 44's H&P examination dated 2/26/25, showed Resident 44 had the capacity to understand and make decisions.
Review of Resident 44's Order Summary Report dated 4/1/2025, showed a physician's order dated 3/8/25, to apply Preparation H External Cream 1%, rectally every day shift for hemorrhoid (swollen vein in the anal canal and lower rectum).
Review of Resident 44's TAR for March 2025 showed missing documentations for the Preparation H External cream medication on the following dates for the day shift (0700-1500 hours):
- on 3/11, 3/18, 3/23, and 3/25/25.
On 4/7/25 at 1038 hours, an observation, interview, and concurrent medical record review was conducted with LVN 9. LVN 9 reviewed Resident 44's medical record and verified the above findings. LVN 9 stated she was scheduled to worked on 3/11, 3/18, and 3/25/25. LVN 9 stated she administered Resident 44's Preparation H cream which was stored at Resident 44's bedside. However, LVN 9 stated she forgot to document the medication administration on the TAR. LVN 9 was asked to show the Preparation H cream stored at the resident's bedside. The Preparation H cream and Lidocaine cream (an anesthetic medication used to prevent and to treat pain from some procedures) 2.5% were observed inside Resident 44's bedside drawer. LVN 9 verified the findings. LVN 9 reviewed Resident 44's medical record and verified the Preparation H cream and Lidocaine cream did not have a physician's order or care plan to be stored at the resident's bedside. Furthermore, LVN 9 stated each medication must have a physician's order, including all the medications stored at the resident's bedside.
On 4/7/25 at 1420 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.
Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and labeling of the medications.
* The facility failed to ensure the orally administered medications were stored separate from the externally used medications in Medication Carts D and E.
* The facility failed to ensure Resident 111's gentamicin (used to treat skin infections) medication was labeled with the opened date.
* The facility failed to ensure Resident 44's Preparation H (medication is used to temporarily relieve swelling, burning, pain, and itching caused by hemorrhoids) external cream and Lidocaine (pain reliever) cream were not stored at the bedside.
These failures had the potential to negatively impact the residents' well-being, and the potential for the medications to lose the stability and effectiveness.
Findings:
Review of the facility's P&P titled Drug Storage and Labeling Drugs and Biologicals (undated) showed oral medications will be stored separately from ointment, creams, lotions, and liquids and for external use.
1. On 4/1/25 at 1056 hours, a medication cart inspection for Medication Cart D was conducted with the ADON. The following was observed inside the first drawer of Medication Cart D:
- one box of AZO (urinary pain relief), one bottle of fish oil (dietary supplement)1000 mg softgels, and one bottle of vitamin B complex (nutritional supplement) were stored with one box of clonidine (medication to treat high blood pressure) transdermal patch, one box of dorzolamide HCL (eye drop to treat increased pressure in the eye) and timolol maleate ophthalmic solution (eye drop to treat increased pressure in the eye) medications.
The ADON verified the above findings.
2. On 4/1/25 at 1210 hours, a medication cart inspection for Medication Cart E was conducted with RN 1. The following was observed:
- one bottle of zinc (mineral supplement) 50 mg tablet and one box of Heparin (blood thinner) injection were stored with one box of Artificial Tears (moisturizing eye drops).
RN 1 verified the above findings.
On 4/2/25 at 1452 hours, an interview was conducted with the DON. The DON was informed and acknowledged of the above findings. The DON stated the external and internal medications should be stored separately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food items were served in the appetizing temperatures as evidenced by:
* The food ...
Read full inspector narrative →
Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food items were served in the appetizing temperatures as evidenced by:
* The food temperatures were below the recommended temperature for hot meats, vegetables, and potatoes. This failure posed the risk for not providing palatable and appetizing food for the residents receiving a meal tray from the kitchen.
Findings:
Review of the facility's Diet Type Report dated 4/1/25, showed 116 of 123 residents consumed the foods prepared in the kitchen.
Review of the facility's P&P titled Meal Service dated 2018 showed meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures. The food will be served on trayline at the recommended temperatures indicated below and recorded on the daily therapeutic menu. Hot food serving temperature must be at or above minimum holding temperature of 140 degrees Fahrenheit. The temperature of the foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperatures. Further review of the facility's P&P showed the service temperature for meat, potatoes and vegetables was 160-180 degrees Fahrenheit. The recommended temperature at the delivery to the resident for hot entrée, starch, and vegetables showed greater than or equal to 120 degrees Fahrenheit.
During the initial tour of the facility and resident interview on 4/1/25, the residents had a concern regarding hot food items were served cold.
Review of the Spring Cycle Menu Week 1 dated for 4/2/25, showed the regular menu included roast turkey with savory cream sauce, herb roasted red potatoes, rosemary cauliflower and peas, fresh green salad, and sherbet.
On 4/2/25 at 1243 hours, a concurrent interview and test tray of the regular menu was conducted with the DSS, and eight surveyors were present. The DSS checked and verified the following temperatures:
- Regular roast turkey with savory cream sauce - 79.7 degrees Fahrenheit;
- Regular rosemary cauliflower and peas - 78.3 degrees Fahrenheit;
- Regular herb roasted red potatoes - 81 degrees Fahrenheit;
- Mechanical soft roast turkey with savory cream sauce - 101 degrees Fahrenheit;
- Mechanical soft rosemary cauliflower and peas - 75.3 degrees Fahrenheit; and
- Mechanical soft herb roasted red potatoes - 86.6 degrees Fahrenheit.
The DSS verified the temperature of the turkey, cauliflower and peas, and herb roasted red potatoes were not hot. The DSS stated the holding temperatures for the hot foods including the meats, vegetables, and potatoes should be over 135 degrees Fahrenheit. The DSS acknowledged the test tray temperatures varying from 75 to 101 degrees Fahrenheit were below the recommended temperatures for a hot meal tray. The DSS stated the hot food should be hot.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following:
1. Active involvement of required individuals in developing the Facility Assessment;
2. Resources necessary to care for residents including weekends;
3. A plan to maximize recruitment and retention of direct care staff; and
4. A contingency plan for staffing needs.
This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.
Findings:
According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency plan for staffing needs for the events not to activate the facility's emergency plan.
Review of the Facility's assessment dated [DATE], did not show the direct care staff member, direct care representatives, residents, residents' representatives, and residents' family members were actively involved in developing the Facility Assessment; the resources necessary to care for the residents including weekends; and a plan to maximize recruitment and retention of the direct care staff, or include a contingency plan for the staffing needs.
On 4/7/25 at 1343 hours, an interview and concurrent facility document review of the Facility Assessment was conducted with the Administrator. The Administrator verified the Facility Assessment was dated 3/15/25, and verified there were no direct care staff, direct care representatives, residents, residents' representatives, and family members actively involved in developing the Facility Assessment. The Administrator further verified there were no resources necessary to care for the residents including on the weekends, and a plan to maximize recruitment and retention of the direct care staff or include a contingency plan for the staffing needs. The Administrator verified and acknowledged the Facility Assessment was not updated based on the latest guidance from the CMS.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and servic...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled residents (Resident 100) reviewed for hospice services.
* The facility failed to ensure Resident 100's HA visits schedule for two times a week was followed per the hospice provider's calendar. This failure posed the risk for delays in the communication between the hospice provider and facility, which may affect the resident care.
Findings:
Review of the facility's P&P titled Hospice Program revised on 7/2017 showed the Hospice providers who contract with this facility are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility.
Review of the facility's contract with Hospice A dated 11/1/24, showed the following:
- Hospice shall designate an interdisciplinary group member who shall be responsible for coordinating with the facility the provision of hospice services to each resident under hospice's care and communicating with the facility and other healthcare providers participating in the provision of care for the resident's terminal illness and related conditions, and other conditions, for ensuring the quality of care;
- Hospice shall deliver hospice services to each resident under hospice's care in a timely manner; and
- Hospice shall notify facility promptly of any change in the designated interdisciplinary group member.
Medical record review for Resident 100 was initiated on 4/3/25. Resident 100 was readmitted to the facility on [DATE].
Review of Resident 100's H&P examination dated 10/5/24, showed Resident 100 had no capacity to make decisions.
Review of Resident 100's MDS assessment dated [DATE], showed Resident 100's BIMS score was three, indicating severe cognition impairment.
Review of Resident 100's Order Summary Report dated 4/1/25, showed a physician's order to admit the resident under the hospice care provided by Hospice A with admitting diagnosis of cerebral infarction (the death of neural (brain) tissue as a result of ischemia).
Review of Resident 100's Hospice A's Patient Calendar for March and April 2025 showed the frequency of the HA visits were every Tuesdays and Thursdays.
Review of Resident 100's Hospice CHHA Flow Sheet did not show the HA visits for 3/25, 3/27, 4/1, and 4/3/25, as per the calendar. Resident 100's flow sheet showed the last HA visit was on 3/20/25.
On 4/3/25 at 0907 hours, an interview and concurrent medical record review was conducted with LVN 11. LVN 11 verified the above findings. LVN 11 stated the HA must visit Resident 100 at least once a week.
On 4/3/25 at 0914 hours, an interview was conducted with Family Member 4. Family Member 4 stated he had not seen the HA visited Resident 100 for the last week of March and this week. In addition, Family Member 4 stated he visited the resident every morning for three to four hours and had not received a call from the HA regarding the changes in the scheduled visits.
On 4/3/25 at 0924 hours, an interview was conducted with the DON. The DON was asked for the frequency of Resident 100's hospice discipline visits and she stated the hospice staff including the RN Case Manager and HA must visit the resident at least once a week or more depending on their calendar schedule. The DON stated the hospice staff must communicate with Resident 100's licensed nurses when they visited and the licensed nurses must document the hospice discipline visit in the resident's medical record. Furthermore, the DON stated all the hospice staff must sign the flow sheet for Resident 100 located in the resident's hospice binder and the MRD checked the hospice binder.
On 4/3/25 at 1338 hours, an interview was conducted with Hospice A Administrator. Hospice A Administrator stated all hospice discipline including the RN Case Manager and HA must sign Resident 100's flow sheet to show the visits and services were completed. In addition, Hospice A Administrator stated the HA must communicate with the facility staff and Resident 100's responsible party or family for any changes in the planned schedule visits. Hospice A Administrator was informed Resident 100's HA scheduled visit were not completed after 3/20/25. Hospice A Administrator stated she would call the assigned HA.
On 4/3/25 at 1359 hours, an interview was conducted with LVN 6. LVN 6 was asked if she was aware of Resident 100's hospice HA visit last week of March and first week of April 2025. LVN 6 stated she worked on 4/1/25, during the day shift and she did not see any visit from the hospice HA nor received a call from Hospice A to reschedule the HA visits.
On 4/3/25 at hours, an interview was conducted with Hospice A Case Manager. Hospice A Case Manager stated the hospice staff must sign the flow sheet with every visit to show the visit was completed and verified the HA's scheduled visits were every Tuesdays and Thursdays. Hospice A Case Manager was informed of Resident 100's missed HA's visits after 3/20/25. Hospice A Case Manager stated he would call the assigned HA for the resident.
On 4/7/25 at 1420 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by:
* The facility fai...
Read full inspector narrative →
Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by:
* The facility failed to ensure the sanitary condition of the hood over the stove was maintained.
* The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition.
* The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue.
* The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface.
* The facility failed to ensure the heavy-duty blender used for puree preparation, scoops used for food portioning, and clear plastic bins were air dried and clean prior to storing and stacking.
* The facility failed to ensure the countertop mounted can opener was in a sanitary condition and free of rust.
* The facility failed to ensure the microwave utilized to warm up the food was in a sanitary condition and free of rust.
These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen.
Findings:
Review of the facility's Diet Type Report dated 4/1/25, showed 116 of 123 residents consumed the foods prepared in the kitchen.
1. Review of the facility's P&P titled Hood, Vents and Filters dated 2018 showed the hoods must be cleaned every two weeks and must be free of dust and grease.
According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean.
On 4/1/25 at 0848 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The kitchen hood over the stove had black, dirt, greasy residue. The DSS acknowledged the findings and stated the dietary staff cleaned the hood once a week and it should be free of dirt and grease for fire hazard prevention.
2. Review of the facility's P&P titled Sanitation dated 2018 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. The plastic ware, China, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. The plastic ware is bleached as necessary to prevent staining.
According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded.
According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
On 4/1/25 at 0848 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed and verified by the DSS:
- Two rubber spatulas with red handles were chipped and cracked at the edges.
- One ladle with black handle was partially melted.
- Two slotted ladles with black handles were partially melted and one ladle was deformed.
- Three stainless steel whisk with rubber handles were partially melted and cracked.
- One white plastic spatula was worn out, discolored, and chipped at the edges.
- One rubber spatula with black handle was discolored, worn out, and chipped at the edges.
- One scoop used for food portioning with gray handle was partially melted.
- One stainless steel dough cutter with white handle was discolored, peeling, and worn out.
The DSS acknowledged the above findings and stated the worn out utensils should have been discarded.
3. Review of the facility's P&P titled Sanitation dated 2018 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas.
Review of the facility's P&P titled Sanitization dated 2001 showed all equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions.
According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
On 4/1/25 at 0848 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed and verified by the DSS:
- Two stainless steel ladle were observed dirty and had dry, crusted residue.
- One slotted stainless steel spoon was observed dirty and had dry, crusted residue and watermarks.
- One slotted stainless steel spoon with black handle was observed dirty and had watermarks.
- One stainless steel cake slicer with black handle was observed dirty and had dry, crusted residue and watermarks.
- One stainless steel spatula with white handle was observed dirty and had dry, crusted residue and watermarks.
- One rubber spatula with red handle was observed dirty and had dry, crusted residue.
- One scoop with white handle used for food portioning was observed with bristle like residue.
- One scoop with black handle used for food portioning was observed dirty and had dry, crusted residue.
- One stainless steel measuring cup was observed dirty and had dry, crusted residue
- One stainless steel dough cutter with white handle was observed dirty with watermarks.
The DSS acknowledged the above findings and stated all the dirty utensils should have been cleaned and washed for bacteria growth prevention and infection control purposes.
4. Review of the facility's P&P titled Sanitation dated 2018 showed separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized.
According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces.
On 4/1/25 at 0848 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The brown and green cutting boards were observed fuzzy, heavily marred and had deep groves. The DSS verified the findings, and stated the cutting boards should have been replaced.
5. Review of the facility's P&P titled Sanitization dated 2001 showed food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination.
Review of the facility's P&P titled Dish washing dated 2018 showed dishes are to be air dried in racks before stacking and storing.
According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food.
According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying.
On 4/1/25 at 0848 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed and verified by the DSS:
- One heavy-duty blender stored on the counter shelf was still wet with visible water inside.
- Three stainless steel ladles were stored wet with visible water inside.
- Six scoops used for food portioning were stored wet with visible water inside.
- One scoop with blue handle used for food portioning was stored wet with visible water and dirty with food residue.
- One scoop with white handle used for food portioning was stored wet with visible water and dirty with food residue.
- One scoop with gray handle used for food portioning was stored wet with visible water and dirty with food residue.
- Six clear plastic bins were observed wet and stacked on top of each other.
The DSS acknowledged the above findings and stated all the utensils, blender, and bins should have been air dried to prevent bacteria growth.
6. Review of the facility's P&P titled Can Opener and Base dated 2018 showed proper sanitation and maintenance of the can opener and base is important to sanitary food preparation. Replace blade on can opener as needed.
According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
On 4/1/25 at 0848 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The countertop mounted can opener was observed with yellowish discoloration resembles a rust on the blade. The DSS verified the findings and stated the can opener should have been replaced.
7. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
On 4/1/25 at 0848 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The microwave on a countertop table was observed old, had yellowish discoloration resembles a rust, and white residue inside the microwave's door. The DSS verified the findings and stated the microwave was old and needed to be replaced.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 5/2024 showed all personnel are expected to adhere to ha...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 5/2024 showed all personnel are expected to adhere to hand hygiene policies to help prevent the spread of infections to others. Hand hygiene is indicated immediately before touching a resident, after touching a resident, and after touching a resident's environment.
On 4/1/25 at 1218 hours, during the dining observation, OT 1 was observed serving Resident 33's lunch tray. OT 1 assisted Resident 33 by opening the covers to her hot water cups and placing a tea bag inside the cup. OT 1 used Resident 33's knife to stir in the tea bag. After assisting Resident 33, OT 1 was observed grabbing a straw from the counter and sat next to Resident 52. OT 1 then placed the straw into Resident 52's cup filled with liquid and held the cup towards the resident's mouth. OT 1 opened the covers to Resident 52's entree. OT 1 was observed turning to their left side and cutting another resident's bread with the resident's knife and fork. OT 1 was then observed wiping Resident 52's mouth with a towel. OT 1 stood up, walked towards the counter and opened multiple drawers. OT 1 then sat down next to Resident 52 and continued to feed her. OT 1 removed the Resident 52's towel placed on her chest and discarded the towel into the soiled barrel. Then, OT 1 was observed grabbing a new towel from a plastic bag filled with clean towels. OT 1 placed the new towel on the resident's chest. OT 1 was observed wheeling Resident 52 out of the dining room and into the resident's room. OT 1 was not observed performing hand hygiene in between helping the residents with their meals.
On 4/1/25 at 1235 hours, an interview was conducted with OT 1. OT 1 verified she help Resident 52 in the dining room during lunch four times a week because self-feeding was part of the resident's OT plan. OT 1 also stated she helped the facility staff during lunch time in the dining room by passing out meal trays to the residents. OT 1 was informed of the dining room observation where she did not perform hand hygiene in between helping residents with their meals. OT 1 verified she did not perform hand hygiene after assisting Resident 33 with her meal tray, prior to helping Resident 52 with her meal, and prior to and after cutting the bread of another resident. OT 1 stated she assumed she did not need to perform hand hygiene in between assisting residents with their meals because she was not in contact with bodily fluids.
On 4/2/25 at 1523 hours, an interview was conducted with the IP. The IP was asked what the expectation was when the facility staff were feeding for multiple residents. The IP stated the expectation was to perform hand hygiene by using the hand sanitizer between each resident care.
On 4/3/25 at 1327 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.
4. On 4/1/25 at 1009 hours, an observation was conducted outside of Resident 3's room. The signage outside of Resident 3's room showed the resident was on EBP. The EBP sign showed the facility staff must wear the gloves and gown for the following high-contact resident care activities: device care or use for feeding tube, central line, urinary catheter, providing hygiene, and wound care. Resident 3 was observed in bed next to an enteral feeding pump.
Medical record review for Resident 3 was initiated on 4/1/25. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 3's diagnosis information dated 9/23/22, showed Resident 3 had a medical history of dysphagia (difficulty swallowing).
Review of Resident 3's H&P examination dated 1/17/25, showed Resident 3 had no capacity to understand and make decisions.
Review of Resident 3's Order Summary Report showed the following physician's orders:
- dated 1/15/25, to administer Jevity 1.2 (enteral feeding formula) via feeding pump at 30 ml per hour for 20 hours.
- dated 1/18/25, to administer water flush via feeding pump at 30 ml per hour for 20 hours.
Review of Resident 3's plan of care showed a care plan problem addressing Resident 3's EBP related to the enteral tube use. The interventions included the facility staff must use gloves and gowns when caring for devices or medical treatments.
On 4/1/25 at 1251 hours, LVN 6 was observed in Resident 3's room wearing gloves but was not wearing the gown. LVN 6 was observed changing Resident 3's enteral feeding formula, water bag, and tubing set. LVN 6 was observed performing hand hygiene and exiting Resident 3's room.
On 4/1/25 at 1310 hours, an interview was conducted with LVN 6. LVN 6 verified she changed and connected Resident 3's enteral feeding. LVN 6 verified Resident 3 was on EBP due to the resident's enteral tube. LVN 6 stated she should have been wearing a gown and gloves when providing high contact resident care. LVN 6 verified she did not wear a gown prior to changing and connecting Resident 3's enteral feeding.
On 4/2/25 at 1416 hours, an interview was conducted with the IP. The IP was asked what the expectation was when a licensed nurse went into a resident's room with EBP to change and connect the resident's enteral feeding. The IP stated the facility staff are expected to wear the proper PPE and perform hand hygiene when providing high-contact resident care. The IP stated the facility staff were aware when a resident was on EBP because there was signage outside of the resident's room, the EBP was included in the resident's care plan, and there was a list of residents with EBP at the nurse stations.
On 4/3/25 at 1327 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.
6. On 4/7/22 at 0904 hours, a wound care treatment observation was conducted with LVN 7. LVN 7 verbalized the wound care treatment was for Resident 111's Stage 4 pressure injuries (full-thickness skin and tissue loss, with exposed muscle, tendon, ligament or bone) to his sacral region and right heel. LVN 7 was observed donning the clean gloves, removing a patch from the resident's sacrum, doffing the dirty gloves, donning the clean gloves, and then applying a dry gauze to wound bed. LVN 7 was observed doffing and donning the gloves throughout wound care treatment without performing hand hygiene immediately after removing his gloves. LVN 7 was observed washing his hands only after applying the dry gauze to the sacral wound and at the end of wound care. Following the sacral wound care, LVN 7 was observed washing his hands for the right heel wound care only prior to treatment and after the treatment, but not immediately after doffing the gloves throughout the right heel wound care treatment.
On 4/7/22 at 0904 hours, a wound care treatment procedure observation was conducted with LVN 7. LVN 7 was observed standing next to the bed of Resident 111 and verbalized hand hygiene had been performed. LVN 7 verbalized wound care treatment was for Resident 111's sacral region pressure ulcer stage four and to the heel of right foot pressure ulcer stage 4. LVN 7 proceeded by donning clean gloves, removed patch from sacrum, doffed dirty gloves, donned clean gloves, and applied dry gauze to wound bed. LVN 7 was observed doffing and donning gloves throughout treatment without performing hand hygiene immediately after glove removal. LVN 7 was observed washing hands only after applying dry gauze to sacral wound and at the end of wound care. Following sacral wound care, LVN 7 was observed washing hands for wound care to heel of the right foot only prior to treatment and after treatment, but not immediately after doffing gloves throughout treatment.
On 4/7/22 at 0923 hours, an interview was conducted with LVN 7. LVN 7 verified hand hygiene should be performed every time the gloves were removed. LVN 7 verified hand hygiene was not performed after doffing the gloves throughout the wound care treatment.
On 4/7/25 at 1305 hours, an interview was conducted with the IP. The IP verified hand hygiene practices were performed before entering a resident's room, when exiting a resident's room, before glove use, after glove use, and before and after each task. The IP also verified the facility staff hands must be sanitized or washed before applying gloves and when removing gloves.
5. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 5/2024 showed the following:
- The facility considers hand hygiene as the primary means to prevent the spread of healthcare-associated infections;
- All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections;
- All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors;
- Hand hygiene is indicated to the following: immediately before touching the resident, before performing an aseptic task, after contact with blood, body fluids, or contaminated surfaces, after touching the resident, after touching the resident's environment, before moving to work on a soiled body site to a clean body site on the same resident, and immediately after glove removal; and
- Single-use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or bloody fluids, and when in contact with a resident, or the equipment or environment of the resident who is on contact precautions. The use of gloves does not replace hand washing/hand hygiene.
Review of the facility's P&P titled Administering Medications revised 5/2024 showed the staff should follow established facility infection control procedures (example: handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.
Medical record review for Resident 370 was initiated on 4/2/25. Resident 370 was admitted to the facility on [DATE].
Review of Resident 370's Order Summary Report showed a physician's order dated 3/26/25, to administer insulin glargine solution (Lantus) 100 units/ml 25 units subcutaneously two times a day for diabetes mellitus.
On 4/2/25 at 0943 hours, a medication administration observation and concurrent interview was conducted with LVN 1. LVN 1 was observed preparing the insulin medication and administering it to Resident 370 after administering all the oral medications to the resident. LVN 1 was observed not performing hand hygiene and changing his gloves prior to the insulin medication preparation and administration to Resident 370. LVN 1 verified he forgot to perform hand hygiene and change the gloves after administering the oral medications and prior to preparing the insulin medication and administration to Resident 370. LVN 1 further stated it was important to perform hand hygiene as part of infection prevention precautions.
On 4/4/25 at 1630 hours, the DON was informed and acknowledged the above findings.
Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections.
* The facility failed to ensure the facility's monthly Infection Prevention and Control Surveillance Log was accurate.
* The facility failed to implement the EBP as per the facility's P&P for Residents 916 with a central line (thin, flexible tube inserted into a large vein near the heart).
* OT 1 failed to perform hand hygiene in between resident care for Residents 33 and 52 during the dining observation.
* LVN 6 failed to don the gown before entering Resident 3's EBP room to change and administer the resident's enteral feeding.
* LVN 1 failed to perform hand hygiene and change gloves prior to the administration of insulin medication for Resident 370.
* The facility failed to ensure LVN 7 practiced sanitary techniques during the wound care treatment.
These failures posed the risk for not identifying the infections and controlling the transmission of communicable diseases to the other residents throughout the facility.
Findings:
1. Review of the facility's P&P titled Infection Prevention and Control revised 3/2024 showed the facility adopted an infection prevention and control program to help prevent to the extent possible the development and transmission of disease and infection. The IP (or designee), under the guidance of the Infection Control Committee and Medical Director shall be responsible to implement the infection prevention and control program.
Review of the facility's monthly Infection Prevention and Control Surveillance Log showed inaccurate documentation for January and February 2025:
- For January 2025, the total number of residents who were screened as HAI were 49 and the total number of CAIs were 43. In addition, the total number of the residents who had met the criteria for true infections were 40 and the total number of the residents who did not met the criteria for true infection were 42. However, the Infection Control Monthly Summary for the Month of January 2025 showed the total number of the residents who were assessed as HAIs were 46 and CAIs were 36. The total number of the residents with infection who met the criteria were 42 and the total number of the resident who did not met the criteria for true infection was 22 . The data from the surveillance log did not match to the monthly reported data of infections of the facility. The reported percentage rate of infection of the facility was inaccurate for January 2025.
- For February 2025, the total number of the residents on the surveillance log who were screened as HAI's were 67 and the total number of CAI's were 18. In addition, the total number of the residents who had met the criteria for true infections were 53 and the total number of residents who did not met the criteria for true infection were 26. However, the Infection Control Monthly Summary for February 2025 showed the total number of the residents who were assessed as HAIs were 35 and CAIs were 14. The total number of residents with infection who met the criteria were 39 and the total number of the resident who did not met the criteria for true infection was 17. The data from the surveillance log did not match to the monthly reported data of infections of the facility. The reported percentage rate of infection of the facility was inaccurate for the month of February 2025.
On 4/7/25 at 0948 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated she used the McGeer and Loeb's criteria to determine a true infection for the residents. The IP added she entered the signs and symptoms, and assessment of the residents who had an infection in the electronic tool found in the resident's EHR to determine a true infection. The electronic tool automatically analyzed the data to determine if it was a true infection or not. The IP stated the infection control summary was reported to the QAPI and used to determine the trend of the infection rate in the facility. The IP was informed of the reported numbers for the HAI and CAI on each month from the surveillance log did not match the total numbers on the infection control monthly summary report for January and February 2025. The IP verified the numbers were inaccurate due to the volume of the infections for those months. The IP stated the numbers of the infection should have matched to the monthly summary report to have an accurate information about the infection control of the facility.
On 4/7/25 at 1112 hours, an interview and concurrent facility document review was conducted with the DON. The DON was informed and verified the above findings.
2. Review of the facility's P&P titled Enhanced Barrier Precautions revised 05/2024 showed the residents with a medical device such as central/vascular catheters was considered a high risk infections and would be placed on Enhanced Barrier Precaution to reduce the transmission of pathogens.
During the initial tour of the facility on 4/1/25 at 0858 hours, Resident 916 was observed in bed. Resident 916 had a PICC line on the right upper arm with a transparent dressing. The transparent dressing was observed with a date label dated 3/31/25. However, Resident 916 was not on EBP. There was no posted signage of the EBP and no available supplies of PPE at the doorway observed.
Medical record review for Resident 916 was initiated on 4/3/25. Resident 916 was admitted to the facility on [DATE].
Review of Resident 916's Order Summary Report dated 4/3/25, showed no documented evidence a physician's order was obtained for Resident 916's EBP related to the resident's central line.
On 4/1/25 at 1602 hours, an observation and concurrent interview for Residents 916 was conducted with RN 1. RN 1 was asked about the facility's P&P for the residents who had a PICC line. RN 1 stated the residents with a central line should be on EBP. RN 1 verified and acknowledged Residents 916 had PICC line and was not placed on EBP per the facility's infection control P&P.
On 4/7/25 at 1012 hours, an interview and concurrent medical record review for Residents 916 was conducted with the DON. The DON was informed and verified the above findings.
MINOR
(B)
Minor Issue - procedural, no safety impact
Safe Environment
(Tag F0584)
Minor procedural issue · This affected multiple residents
Based on observation and interview, the facility failed to provide a safe, clean homelike environment in three of 50 resident rooms (Rooms A, B, and C). This failure posed the risk of the residents no...
Read full inspector narrative →
Based on observation and interview, the facility failed to provide a safe, clean homelike environment in three of 50 resident rooms (Rooms A, B, and C). This failure posed the risk of the residents not having a sanitary, comfortable living space and potential to negatively impact the residents' quality of life.
Findings:
1. On 4/1/25 at 0817 hours, an observation of Room A was conducted. The vent cover inside Room A was observed with rust and black substance around the vent cover. In addition, a hole measuring approximately one inch in diameter was observed on the ceiling above a resident's bed inside Room A.
On 4/1/25 at 1600 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director verified the above findings.
2. On 04/1/25 at 0912 hours, an observation of Room C was conducted. The footboard for a resident's bed inside Room C was observed with ripped corners exposing the inner cardboard surface of the footboard.
On 4/1/25, at 1548 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director verified the above findings.
3. On 4/1/25 at 1607 hours, an observation and concurrent interview was conducted with the IP. The footboards of the residents' beds (three beds) inside Room B were observed with ripped corners exposing the inner cardboard surface of the footboards. The IP verified the findings.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0625
(Tag F0625)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident and/or their repr...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital for one of two final sampled residents (Resident 3) reviewed for hospitalization. This failure had the potential for Resident 3 and/or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period.
Findings:
Review of the facility's P&P titled Bed-Holds and Returns revised 10/2022 showed it is the policy of the facility to inform the resident or the resident's representative with the written information regarding their right to exercise the bed hold provision during periods of absence upon admission and provide a second notice before transfer to a general acute care hospital or before the resident goes on a therapeutic leave. In the event of an emergency transfer, the second notice will be provided within 24 hours.
Medical record review for Resident 3 was initiated on 4/1/25. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 3's Order Summary Report showed a physician's order dated 1/9/25, to send Resident 3 to the acute care hospital due to decreased oxygen saturation (amount of oxygen in the blood) level.
Review of Resident 3's eInteract Transfer Form v5 dated 1/9/25 at 0758 hours, showed Resident 3 was transferred to the acute care hospital.
Review of Resident 3's medical record did not show if the written information regarding the facility's bed hold policy was provided to Resident 3's representative when Resident 3 was transferred to the acute care hospital on 1/9/25.
Review of Resident 3's H&P examination dated 1/17/25, showed Resident 3 had no capacity to understand and make decisions.
On 4/3/25 at 1042 hours, an interview and concurrent medical record review for Resident 3 was conducted with LVN 3. LVN 3 verified Resident 3 was transferred to the acute care hospital on 1/9/25. LVN 3 was not able to show documented evidence Resident 3 or their representative was provided with the written information regarding the facility's bed hold policy when Resident 3 was transferred to the acute care hospital on 1/9/25. LVN 3 verified the findings and stated the bed hold notification form should be completed upon the resident's transfer to the acute care hospital.
On 4/3/25 at 1327 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.
MINOR
(B)
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for four o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for four of 28 final sampled residents (Residents 20, 29, 65, and 70) were accurate and complete.
* The facility failed to ensure the Inventory of Personal Effects for Resident 20 was reviewed with and signed by the resident's representative upon the resident's admission to the facility.
* The facility failed to ensure the Inventory of Personal Effects for Resident 29 was reviewed with and signed by the resident's representative upon the resident's admission to the facility.
* Resident 65's POLST was incomplete and did not show the physician's phone number, the resident's signature, address and phone number, and the date when the POLST was completed by the resident.
* Resident 70's POLST was incomplete and did not show the physician's phone number, license number, the resident's responsible party's signature, address and phone number, and the date when the POLST was completed by the responsible party. In addition, the facility failed to ensure the Inventory of Personal Effects for Resident 70 was reviewed with and signed by the resident's representative upon the resident's admission to the facility.
These failures had the potential for the residents' care needs not being met as their medical information were incomplete and/or inaccurate. In addition, this had the potential for the resident's representative to ensure all of the resident's personal effects/belongings were accounted for.
Findings:
1. Review of the facility's P&P titled Personal Property date revised 3/2021 showed the resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary.
Medical record review for Resident 20 was initiated on 4/1/25. Resident 20 was admitted to the facility on [DATE].
Review of Resident 20's Inventory of Personal Effects undated showed the section for the signature of the resident or responsible party was left blank and undated.
Review of Resident 20's Inventory of Personal Effects dated 2/4/23, showed the signature for the resident or responsible party was left blank and undated.
2. Medical record review for Resident 29 was initiated on 4/1/25. Resident 29 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 29's Inventory of Personal Effects undated showed the section for the signature of the resident or responsible party was left blank and undated.
On 4/7/25 at 1418 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings for Residents 20 and 29. The DON stated the inventory of the resident's personal effects and belongings was done by the CNA upon the resident's admission to the facility. The DON stated the residents' inventory lists should have been completely filled out to account for the residents' personal belongings.
3. Medical record review for Resident 65 was initiated on 4/1/25. Resident 65 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 65's POLST dated 5/8/24, showed under Section D - Information and Signatures, the physician's telephone number and the resident's address and telephone number were left blank and undated.
4. Medical record review for Resident 70 was initiated on 4/1/25. Resident 70 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 70's POLST dated 5/7/24, showed under Section D - Information and Signatures, the physician's telephone number, license number, and the resident's name, signature, address and telephone number were left blank and undated.
Review of Resident 70's Inventory of Personal Effects undated showed the section for the signature of the resident or responsible party was left blank and undated.
Review of Resident 70's Inventory of Personal Effects dated 1/1/24, showed the section for the signature of the resident or responsible party was left blank and undated.
On 4/7/25 at 1418 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings for Residents 65 and 70. The DON stated the POLST was completed by the RN upon the resident's admission to the facility and followed up by the social services staff. The DON stated the POLSTs for Residents 65 and 70 should have been completely filled out because it contained relevant information.
Jan 2025
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B when the facility failed to report an allegation of resident-to-resident abuse to the CDPH, L&C Program and to the local ombudsman for one of the nine sampled residents (Resident 5). This failure had the abuse allegation going unreported and uninvestigated.
Findings:
Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating revised 9/2022 showed all the reports of the resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigation are documented and reported.
Closed medical record review for Resident 5 was initiated on 1/31/25. Resident 5 was admitted to the facility on [DATE] and discharged on 7/31/24.
Review of Resident 5's H&P examination dated 7/16/22, showed Resident 5 had the capacity to understand and make decisions.
Review of Resident 5's Progress Notes showed an entry dated 7/31/24, by the SSD. The SSD documented Resident 5 was verbally abusive to the roommate. Resident 5 was threatening the roommate the whole night. The roommate was scared Resident 5 might do something. The Administrator was aware of the situation and called the physician.
On 1/31/25 at 1452 hours, an interview was conducted with the DON. The DON verified the allegation of the resident-to-resident abuse was not reported to CDPH, L&C program ombudsman or to the police.
On 1/31/25 at 1615 hours, an interview was conducted with the Administrator. The Administrator acknowledged the facility did not report aforementioned resident-to-resident abuse allegation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to implement their abuse P&P related to ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to implement their abuse P&P related to investigation of the resident-to-resident abuse for one of nine sampled residents (Resident 5).
* The facility failed to conduct a thorough investigation when Resident 5 was reported to be verbally abusive to the roommate. This failure posed a risk for the resident to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse.
Findings:
Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating revised 9/2022 showed all the allegations are thoroughly investigated. The Administrator initiates the investigations. Within five business days of the incident, the Administrator will provide a follow-up investigation report.
Closed medical record review for Resident 5 was initiated on 1/31/25. Resident 5 was admitted to the facility on [DATE] and discharged on 7/31/24.
Review of Resident 5's H&P examination dated 7/16/22, showed Resident 5 had the capacity to understand and make decisions.
Review of Resident 5's Progress Note showed an entry dated 7/31/24, by the SSD. The SSD documented Resident 5 was verbally abusive to the roommate. Resident 5 was threatening the roommate the whole night. The roommate was scared Resident 5 might do something. The Administrator was aware of the situation and called the physician.
On 1/31/25 at 1452 hours, an interview was conducted with the DON. The DON verifiedthe facility did not do an investigation regarding the resident-to-resident abuse allegation.
On 1/31/25 at 1615 hours, an interview was conducted with the Administrator. The Administrator acknowledged the facility did not conduct an investigation regarding the aforementioned resident-to-resident abuse allegation.
Cross reference to F609.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of nine sampled residents (Resident 1) was free from the unnecessary psychotropic medications.
* The facility failed to obtain the informed consent from Resident 1 or surrogate decision maker for the use of lorazepam (a drug used to relieve anxiety) and when there was an increase in the dosage of the citalopram (a drug used to treat depression) medication.
* The facility failed to ensure Resident 1 was provided with the non-pharmacologic interventions for the use of the citalopram, quetiapine fumarate (a drug that can treat schizophrenia, bipolar disorder and depression), and buspirone (a drug used to treat anxiety) medications.
These failures have the potential to negatively affect Resident 1's well-being.
Findings:
Medical record review for Resident 1 was initiated on 1/29/25. Resident was admitted to the facility on [DATE] and readmitted on [DATE].
a. Review of Resident 1's Order Summary Report showed the following physician's orders:
- dated 12/19/24, for buspirone 5 mg three times a day for anxiety manifested by verbalization of feeling anxious, citalopram 30 mg one time a day for depression manifested by episodes of crying, and quetiapine fumarate 25 mg one tablet at bedtime for episodes of yelling outbursts leading to exhaustion; and
- dated1/12/25, for lorazepam 0.5 mg every twelve hours as needed for anxiety manifested by restlessness for fourteen days or until 1/26/25.
Review of Resident 1's Informed Consent – Psychoactive Medication showed an informed consent was obtained from the surrogate decision maker for the following medications:
- on 4/11/24, for the use of the buspirone 5 mg for anxiety manifested by verbalization of anxiety, citalopram 20 mg for depression manifested by verbalization of feeling sad, and lorazepam 0.5 mg every six hours as needed for verbalization of feeling anxious; and
- on 8/23/24, for the use of the Seroquel (quetiapine fumarate) 50 mg for psychosis manifested by inconsolable episodes of crying out.
However, there was no documentation of an informed consent obtained from Resident 1 or surrogate decision maker for the increase in the dosage of the citalopram and when the lorazepam medication order was renewed on 1/12/25.
b. Review of the facility's P&P titled Antipsychotic Medication Use revised 7/2022 showed the residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situations. For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacologic interventions.
Review of Resident 1's MAR for January 2025 showed Resident 1 had the following physician's order and was administered the following medications:
- buspirone 5 mg three times a day for anxiety daily from 1/1 to 1/29/25;
- citalopram 30 mg one time a day for depression daily from 1/1 to 1/29/25;
- quetiapine fumarate 25 mg one tablet at bedtime for episodes of yelling outbursts leading to exhaustion daily from 1/1 to 1/29/25; and
- lorazepam 0.5 mg every 12 hours as needed for fourteen days manifested by yelling out on 1/26/25 at 1742 hours.
Review of Resident 1's medical record failed to show documented evidence Resident 1 was provided with the non-pharmacologic interventions for the psychotropic medications use.
On 1/30/25 at 1043 hours, a concurrent interview and medical record review was conducted with LVN 9. LVN 9 stated Resident 1 was on routine buspirone, citalopram, and quetiapine medications; and as needed lorazepam medication. LVN 9 was asked if there was an informed consent on Resident 1's increased in the dosage of the citalopram medication and for the new order of as needed lorazepam medication. LVN 9 was unable to provide documentation. Furthermore, LVN 9 was asked if there was any non-pharmacologic intervention provided to Resident 1, LVN 9 was unable to provide documentation.
On 1/31/25 at 1452 hours, a concurrent interview and medical record review was conducted with the DON. The DON confirmed there were no informed consent obtained from Resident 1 or surrogate decision maker for the use of as needed lorazepam medication or increased dosage of the citalopram medication. The DON also confirmed there was no documentation of the non-pharmacological interventions provided to Resident 1 for the use of the psychotropic medications.
The Administrator was made aware and acknowledged the above findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the resident's food preferences and allergies were considered and adhered to for one of nine sampled residents (Resident 4).
* The facility failed to ensure Resident 4 was not served food containing fish as Resident 4 was allergic to fish. This failure caused an adverse reaction on Resident 4's well-being.
Findings:
Review of the facility's P&P titled Tray Identification revised 4/2007 showed the appropriate identification/coding shall be used to identify various diets. To assist in setting up and serving the correct food trays/diets to residents, the food services department will use appropriate identification (example color coded or computer-generated diet cards) to identify the various diets. The food services manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. The nursing staff check each food tray for the correct diet before serving the residents. If there is an error, the nurse supervisor will notify the dietary department immediately by phone so that the appropriate food tray can be served.
Medical record review was initiated for Resident 4 on 1/29/25. Resident 4 was admitted to the facility on [DATE]. Resident 4 was allergic to fish.
Review of Resident 4' s H&P examination dated 1/15/25, showed Resident 4 hadthe capacity to understand and make decisions.
Review of Resident 4's Plan of Care initiated and revised on 1/15/25, showed a care plan problem addressing the risk for an allergic reaction due to food allergy to fish.
On 1/30/25 at 1605 hours, an interview and concurrent facility document review was conducted with the DSS. Review of the facility's menu for 1/13 to 1/19/25, showed grilled chicken breast on a bun for dinner on 1/19/25. Further review of the document showed the grilled chicken was stroked-out and breaded fish was written on top of the grilled chicken with initials. The DSS verified the menu had changed to breaded fish. The DSS stated he put his initial when the menu had changed.
Review of Resident 4's Progress Note on 1/19/25 at 1815 hours, showed the residenthad an episode of allergic reaction to fish dueto consuming fish which was served as sandwich protein. The resident's allergy to fish was established and documented. The resident's dinner slip showed the grilled chicken as the protein in the sandwich. The notes also showed the inability to correctly identify the sandwich protein as fish during inspection of trays prior to having patients be served, arose from the fact the fish was shredded and mixed with other ingredients/condiments. The notes further showed the LVN's documentation stating for the food content identification, I relied entirely on the dinner slip which showed grilled chicken.
Review of Resident 4's Progress Note on 1/19/25 at 1830 hours, showed Resident 4 was served a fish sandwich on the dinner tray. Per the resident, I took a bite out of the sandwich, when my throat and neck started to feel heavy. That is when I realized that I took a bite out of a fish sandwich. The notes further showed the physician was notified and ordered to transfer Resident 4 to the acute care hospital via 911.
Review of Resident 4' SBAR Communication Form dated 1/19/25, showed at 1830 hours, Resident 4 was served a fish sandwich on the dinner tray and had an allergy to fish. Resident 4 was transferred out via 911 to the acute care hospital.
Review of Resident 4's Emergency Department Provider Note dated 1/19/25, Resident 4 was brought to the emergency department because of possible allergic reaction after eating fish at dinner. Resident 4 got anxious and felt warm all over. Resident 4's After Visit Summary dated 1/19/25, showed the anxiety and allergic reaction were the reasons for the visit. Further review of the Emergency Department Provider Note showed the differential diagnosis included allergic reaction, anxiety/panic attack, generalized pain/chronic pain among other entities.
On 1/29/25 at 1510 hours, an interview was conducted with Resident 4. Resident 4 was asked for his allergies, and he stated fish. Resident 4 stated the facility thought a chicken sandwich was served but a fish sandwich was served instead. Furthermore, Resident 4 stated after taking a bite or two of the sandwich he felt he could not breath and felt heavy on the throat.
On 1/30/25 at 1446 and 1605 hours, a concurrent interview and facility document review was conducted with the DSS. The DSS stated on admission, the resident was asked about likes/dislikes and allergies. The nursing staff member checked each of the food tray if it was correct before serving to the residents. The DSS was asked why the grilled chicken was stroked out from the dinner menu on 1/19/25, the DSS stated on 1/17/25, the vendor was out of grilled chicken, so the menu was changed to breaded fish. Furthermore, the DSS verifiedthe change in the menu had been communicated to the nursing staff.
On 1/31/25 at 1408 hours, an interview was conducted with RN 1. RN 1 stated during the meal distribution, the nursing staff had compared the meal ticket with the diet list and lift the lid of the meal tray to confirm if the meal was the same with the meal ticket. The meal ticket included the resident's likes, dislikes, and allergies. If there was a change in the menu, the DSS communicated the changes to the nursing staff.
On 1/31/25 at 1452 hours, an interview was conducted with the DON. The DON stated the medications could not be placed in the PCC if the allergy section was not filled out. The DON was asked about the process for tray distribution, the DON stated the licensed nurse would have a diet printout to match the diet slip. The licensed nurse opened the meal tray to confirmed if the tray had the right diet. If there were changes in the menu, it would be communicated by the DSS at the 0930 hours meeting with all the department heads. The changeswould also be communicated to the nursing staff.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Safe Environment
(Tag F0921)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and facility P&P review, the facility failed to ensure the facility's environmental conditions were kept sanitary as evidenced by:
* The toilet/bathroom shared by Room...
Read full inspector narrative →
Based on observation, interview, and facility P&P review, the facility failed to ensure the facility's environmental conditions were kept sanitary as evidenced by:
* The toilet/bathroom shared by Rooms A and B was observed with several used washcloths and a yellow and pink pitcher by the sink with no label.
* The Dirty laundry collection rolling bin was observed to be with brown colored residue located on the top corner of the bin and was observed to be touched with bare hands several times by the facility staff member while pushing the bin.
These failures posed the risk of unsanitary and unsafe conditions for the residents, staff, and visitors.
Findings:
1. Review of the facility's P&P titled Homelike Environment revised on 2/2021 showed the residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment.
On 1/29/25 at 1500 hours, an observation of the toilet/bathroom shared by Rooms A and B was conducted with RN 3. The toilet was observed with the following:
- used washcloths by the sink, on top of the paper towel dispenser and hanging at the toilet seat lid; and
- a yellow and pink pitcher with no label by the sink.
RN 3 stated the CNA should have collected the used washclothsand placed in the dirty linen. The pitcher should always be labeled and should not be in the toilet. RN 3 acknowledged the used items in the toilet/bathroom can be accidentally used by another resident.
On 1/31/25 at 1615 hours, the Administrator and DON were made aware and acknowledged the above findings.
2. Review of the facility's P&P titled Laundry and Bedding, Soiled revised on 9/2022 showed the linen carts are cleaned and disinfected whenever visibly soiled and according to the established schedule. Separate carts are used for transporting clean and contaminated linen. Otherwise, carts that are used for transport of dirty linen are thoroughly cleaned and disinfected before being used to transport clean linen.
On 1/31/25 at 0900 hours, an observation was conducted atStation 1 hallway. A dirty laundry collection rolling bin was observed with brown residue on the top corner of the bin. The bin was located across the Administrator's office.
On 1/31/25 at 1035 hours, a concurrent interview and observation was conducted with CNA 2. CNA 2 was observed to be pushing the dirty laundry collection rolling bin with bare hands near Station 1 hallway. The bin was still observed to have brown colored residue on the top corner and CNA 2 was observed touching the brown colored residue many times while pushing the bin. CNA 2 was asked what could be the brown colored residue found on top of the corner of the bin. CNA 2 stated that it could be a bowel movement stain from a dirty linen. The CNA 2 further stated the bin should have beencleaned and gloves should be worn to prevent spread of infection and to maintain good hygiene and sanitation of the bin.
On 1/31/25 at 1449 hours, an interview was conducted with the DON. The DON stated the bin should have been cleaned and CNA should have worn gloves at least to maintain good hygiene and sanitation of the dirty laundry bin and to prevent the spread of infection.
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for two of eight sampled residents (Residents 1 and 2).
* The facility failed to ensure the necessary care and services were provided timely for Resident 2 who had a fall. Additionally, Resident 1's physician ordered the CBC, CMP, and UA with culture laboratory tests; however, the facility failed to perform these laboratory tests.
* The facility failed to complete the neurological assessments following Resident 1's unwitnessed fall on 11/23/24.
These failures had the potential for the delay of care provided and poor health outcomes for the residents.
Findings:
1. Closed medical record review for Resident 2 was initiated on 1/6/25. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE].
a. Review of the facility's P&P titled Fall – Clinical Protocol revised 3/2018 under the Assessment and Recognition section, showed the nurse shall assess and document/report the following: vital signs; recent injury; musculoskeletal function, observing for change in normal range of motion, weight bearing; change in condition or level of consciousness; neurological status; pain; frequency and number of falls since last physician visit; precipitating factors, details on how fall occurred; all current medications and all active diagnoses. The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. Fall should be categorized as (a) those that occur while trying to rise from a sitting or lying to an upright position; (b) those that occur while upright and attempting to ambulate; and (c) other circumstances such as sliding out of a chair or rolling from a low bed to the floor. Falls should also be identified as witnessed or unwitnessed events.
Under the Cause Identification section, showed for an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable.
Under the Treatment/Management section showed based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.
Under the Monitoring and Follow-Up section, showed the staff, with the physician's guidance, will follow-up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out of resolved. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.
Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/ mental condition and/ or status. The nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury including injuries of an unknown source.
Review of the facility's P&P titled Falls and Fall Risk, Managing, revised 3/2018 showed based on previous evaluations and current data, the staff may identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
Review of Resident 2's plan of care showed a care plan focus dated 11/22/24, addressing Resident 2's risk for falls related to antidepressant medication. The interventions included to monitor for changes in condition affecting risk for falls and notify physician if observed.
Review of Resident 2's SBAR Communication Form dated 12/24/24 at 1431 hours, showed Resident 2 sustained a fall and was seen by a CNA to slide down from the wheelchair in the hallway due to seat cushion slipping forward, did not sustain a head injury, no bodily harm was noted, and no complaints of pain or discomfort. The primary care clinician was notified and recommended neuro checks.
Review of Resident 2's Nurse's Note dated 12/26/24 at 2146 hours, written by LVN 1 showed one fall noted this shift; no injuries noted; vital signs within normal limit; resident assisted back to bed and educated on importance of call light use.
Further review of the medical records showed no documented evidence an assessment of Resident 2 was completed regarding the documented fall on 12/26/24. There was no documented evidence the physician and/or resident's representative were notified of the incident. There was no documentation to show the actual time when Resident 2 was found on the floor.
Review of Resident 2's Alert Charting note dated 12/28/24 at 1710 hours, showed during rounds around 1630 Resident 2 was found on the floor mat lying on his back. Asked Resident 2 what happened, Resident stated I'm trying to turn to my side and slid off. Resident alert to name and place, denies pain or discomfort noted. Assessment done, no bruise, and no bump noted. Assisted the resident back to the bed with three persons and made comfortable. The Physician was notified and obtained new order to do CBC, CMP, and neuro checks for 72 hours. Noted and carried out orders. Responsible party was made aware and agreeable.
Further review of Resident 2's plan of care showed a care plan focus dated 12/28/24, addressing Resident 2's unwitnessed fall and was at risk for injury, recurring falls. However, Resident 2's care plan was not updated to reflect the falls which occurred on 12/24/24 and 12/26/24.
On 1/8/25 at 1439 hours, a concurrent interview and medical record review was conducted with the DON. The DON was informed of the above findings. The DON stated she was not sure what was meant when LVN 1 wrote the Nurse's Note dated 12/26/24 and would need to follow up with LVN 1. The DON stated their process when a resident falls, would be to do a change of condition evaluation, notify the physician and the resident's family, update the care plan with what the physician's orders, and 72-hour monitoring. The DON stated the MDS Coordinator or desk nurse would update the care plan regarding the fall. The DON verified Resident 2's care plan was not updated to address Resident 2's falls on 12/24/24 or 12/26/24.
On 1/8/25 at 1620 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 2 was a risk for falls. LVN 1 stated on 12/26/24, Resident 2 had an incident with her towards the end of her shift at 2030-2100 hours. LVN 1 stated Resident 2 was on a low-air-loss mattress, slid off the mattress, and was found sitting on his bottom on the floor. LVN 1 stated there were already CNAs in the room to see if Resident 2 was okay and they waited for her to come and see the resident. LVN 1 stated she then took his vital signs, assessed him for injuries, and assisted him back to bed. LVN 1 verified she did not conduct a new change of condition evaluation because Resident 2 was already being monitored for the fall occurring on 12/24/24. LVN 1 stated there was no other change of condition noted, no injuries or vital signs change; and if anything further needed to be done then she would have taken the steps per their facility's protocol.
On 1/8/25 at 1626 hours, the DON was informed of and acknowledged the findings. The DON verified LVN 1 should go through the facility's protocol for falls.
b. Review of the facility's P&P titled Lab and Diagnostic Test Results – Clinical Protocol, revised 11/2020, showed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests.
Closed medical record review for Resident 2 was initiated on 1/6/25. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE].
Review of Resident 2's SBAR Communication Form dated 12/24/24 at 1431 hours, showed Resident 2 had a change in condition. Resident 2 was noted to be mumbling words and restless. Resident 2's physician was noted and ordered a CBC, CMP, and UA and urine culture. All orders were placed and carried out.
Review of Resident 2's Order Summary Report dated 1/8/25, showed the following completed physician's orders dated:
- 12/25/24, for CBC, CMP; and
- 12/25/24, for UA and urine culture.
Review of Resident 2's medical record failed to show Resident 2's CBC, CMP, and UA and urine culture was obtained as ordered by the physician on 12/25/24.
On 1/8/25 at 1439 hours, a concurrent interview and medical record review was conducted with the DON. The DON was asked to show documentation Resident 2 had a CBC, CMP, and UA and urine culture laboratory tests drawn as ordered by the physician in 12/25/24. The DON reviewed Resident 2's medical record and was unable to locate documented evidence Resident 2's laboratory tests had been obtained in accordance with the physician's order.
2. Medical record review for Resident 1 was initiated on 1/6/25. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE].
Review of Resident 1's H&P examination dated 9/10/24, showed Resident 1 had no capacity to understand and make decisions.
Review of Resident 1's Order Summary Report dated 1/14/25, showed the following physician orders:
- dated 10/28/24, to provide a 1:1 sitter (one resident: one staff) and
- dated 11/24/24, for neuro check for 72 hours every shift, status post unwitnessed fall for three days
Review of Resident 1's SBAR Communication Form dated 11/23/24, showed Resident 1 had a change in condition related to a fall. Resident 1 was noted to fall out of the geri-chair to the ground. The caregiver was in the restroom at the time of the fall and did not notify the staff he was leaving the resident. Resident 1 was found on the floor facing down, noted skin tears on bilateral elbows and left palm. Resident 1's physician was notified and recommended to send the resident to the acute care hospital for further evaluation.
Further review of Resident 1's medical record showed he returned to the facility on [DATE]. There was no documented evidence the neuro checks were completed for 72 hours after Resident 1's unwitnessed fall.
On 1/7/25 at 1159 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 stated Resident 1 had a 1:1 sitter and could try to get up by himself but was not stable. LVN 2 stated Resident 1 required assistance to get out of bed and for activities of daily living. LVN 2 stated post-fall, monitoring for the resident would be done for 72 hours and would complete neuro checks if they were not sure if the resident hit their head/unwitnessed fall or if the physician ordered it. LVN 2 verified there was no documented evidence a neuro check was completed for Resident 1's fall on 11/23/24.
On 1/7/25 at 1328 hours, a concurrent interview and medical record review was conducted with the DON. The DON reviewed Resident 1's medical record and stated Resident 1 came back to the facility within a few hours after being sent to the acute care hospital. The DON verified there was no neuro check completed after Resident 1's unwitnessed fall on 11/23/24.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of eight samp...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of eight sampled residents (Residents 1 and 8) were free from unnecessary psychotropic drugs.
* Resident 1, who had diagnoses including dementia, was prescribed lorazepam (antianxiety medication) PRN for anxiety manifested by restlessness. There was no documented diagnosis, or diagnosis of anxiety prior to starting the PRN lorazepam medication. Additionally, Resident 1's physician's orders for the lorazepam medication were continuously renewed PRN for 14 days and eventually extended to be given PRN for 30 days. There was no documented evidence of the evaluation for the renewal of the PRN lorazepam medication order nor rationale from the prescribing practitioner to indicate why it was appropriate for the PRN lorazepam medication order to be extended beyond 14 days.
* Resident 8, who had diagnoses including dementia, was prescribed risperidone (antipsychotic medication) for psychosis manifested by inconsolable episodes of calling out. There was no documented diagnosis of psychosis prior to starting the risperidone medication.
These failures had the potential to place the residents at risk for receiving unnecessary medications and increased risk of serious medication adverse reactions.
Findings:
1. Medical record review for Resident 1 was initiated on 1/6/25. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE].
Review of Resident 1's H&P examination dated 8/30/24, showed Resident 1 had no capacity to understand and make decisions. The H&P examination failed to show a diagnosis of anxiety for the use of the PRN lorazepam medication.
Review of Resident 1's H&P examination from the acute care hospital dated 9/6/24, showed Resident 1 had a past medical history of anxiety.
Further review of Resident 1's medical record failed to show a documented diagnosis of anxiety prior to 9/6/24.
Review of Resident 1's Order Summary Report, dated 1/14/25, showed the following physician's orders:
- dated 8/31/24 and discontinued on 9/14/24, for lorazepam oral tablet two mg, give one tablet by mouth every four hours PRN for restlessness for 14 days;
- dated 9/5/24 and discontinued on 9/19/24, for lorazepam oral tablet 0.5 mg, give 0.5 mg by mouth every six hours PRN for anxiety manifested by increased restlessness for 14 days;
- dated 9/10/24 and completed on 9/24/24, for lorazepam oral tablet 0.5 mg, give one tablet by mouth every six hours PRN for anxiety for 14 days manifested by restlessness;
- dated 9/25/24 and completed on 10/9/24, for lorazepam oral tablet 0.5 mg, give one tablet by mouth every six hours PRN for anxiety for 14 days manifested by restlessness;
- dated 10/11/24 and completed on 10/25/24, for lorazepam oral tablet 0.5 mg, give one tablet by mouth every six hours PRN for anxiety for 14 days manifested by restlessness;
- dated 10/25/24 and completed on 11/8/24, for lorazepam oral tablet 0.5 mg, give one tablet by mouth every six hours PRN for anxiety for 14 days manifested by restlessness;
- dated 11/11/24 and completed on 11/25/24, for lorazepam oral tablet 0.5 mg, give one tablet by mouth every six hours PRN for anxiety for 14 days manifested by restlessness;
- dated 11/26/24 and completed on 12/26/24, for lorazepam oral tablet 0.5 mg, give one tablet by mouth every six hours PRN for anxiety for 30 days manifested by increased restlessness;
- dated 12/6/24 and completed on 12/20/24, for lorazepam solution 2mg/ ml, inject 0.5 mg intramuscularly every 12 hours PRN for agitation/restlessness for 14 days; and
- dated 12/26/24, to be completed on 1/25/25, for lorazepam oral tablet one mg, give one tablet by mouth every six hours PRN for anxiety for 30 days manifested by increased restlessness.
Review of Resident 1's Psychiatric Note dated 12/26/24, showed a plan for Resident 1 to be started on Seroquel (quetiapine fumarate, an antipsychotic medication) medication and to continue the lorazepam medication.
Further review of Resident 1's medical record failed to show documented evidence of the justification and clinical indication regarding why Resident 1's PRN lorazepam medication orders were continuously renewed after completed. Additionally, Resident 1's medical record failed to show documented evidence of a clinical rationale for the PRN lorazepam medication order to be extended beyond 14 days to 30 days from 11/26/24 to 12/26/24 and 12/26/24 to 1/25/25.
On 1/6/25 at 1212 hours, 1/6/25 at 1229 hours, 1/6/25 at 1240 hours, 1/6/25 at 1256 hours, 1/6/25 at 1313 hours, 1/6/25 at 1321 hours, Resident 1 was observed laying in bed sleeping. Resident 1's lunch tray was observed on his bedside table, untouched.
On 1/6/25 at 1321 hours, a concurrent observation and interview was conducted with CNA 1. CNA 1 stated Resident 1 had been asleep since 1000 hours. CNA 1 stated Resident 1 was agitated this morning, and the nurse gave him medications which may have calmed him down too much. CNA 1 stated Resident 1 was a high fall risk, a danger to himself, and was not stable.
On 1/7/25 at 0845 hours, a concurrent observation and interview was conducted with CNA 3. CNA 3 stated Resident 1 was very aggressive and would think he was breaking into his house.
On 1/7/25 at 1159 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 was not able to provide documented evidence showing Resident 1 was diagnosed with anxiety and would need to clarify with the physician. LVN 2 stated for the PRN orders for the use of the psychotropic drugs, before 14 days the resident would need to be reevaluated and if the resident did benefitedfrom the medication, we would notify the physicianthen extend the order for 30 or 60 days. LVN 2 verified there was no documented evidence of appropriateness for Resident 1's PRN lorazepam medication order to be extended beyond 14 days.
On 1/7/25 at 1515 hours, a follow up interview was conducted with CNA 1. CNA 1 stated Resident 1 woke up around 1450 hours the day prior. CNA 1 stated Resident 1 was normally confused and could get aggressive.
On 1/8/25 at 0910 hours, a concurrent interview and medical record review was conducted with the DON. The DON stated Resident 1 was taking the lorazepam medication for restlessness because he was anxious. The DON verified there was no documented evidence of a diagnosis of anxiety prior to Resident 1 being starting the PRN lorazepam medication. The DON verified there was no documented evidence the physician had evaluated Resident 1 for the appropriateness of the renewal of the PRN lorazepam medication orders nor documented clinical rational to extend the PRN lorazepam medication orders beyond 14 days.
2. Review of the FDA black box warning for prescribing risperidone showed elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidone is not approved for the treatment of patients with dementia-related psychosis.
Medical record review for Resident 8 was initiated on 1/7/25. Resident 8 was admitted to the facility on [DATE].
Review of Resident 8's H&P examination dated 9/10/24, showed Resident 1 had no capacity to understand and make decisions. The H&P examination failed to show a diagnosis of psychosis for the use of the risperidone medication.
Review of Resident 8's Order Summary Report, dated 1/14/25, showed a physician's order dated 12/10/24 for risperidone oral tablet 0.25 mg, give one tablet by mouth one time a day for psychosis manifested by inconsolable episodes of calling out.
Review of Resident 8's Psychiatric Note dated 12/26/24 showed Resident 8 was diagnosed with psychosis and a plan to increase Resident 8's risperidone to 0.25 mg three times a day.
On 1/6/25 at 1321 hours, a concurrent observation and interview was conducted with CNA 1. Resident 8 was observed laying down in bed and attempting to get up out of bed by himself. An audible bed alarm is heard when Resident 8 starts to stand up. CNA 1 was observed to redirect Resident 8 back to bed. CNA 1 stated Resident 8 was a fall risk.
On 1/7/25 at 0845 hours, a concurrent observation and interview was conducted with CNA 3. CNA 3 stated Resident 8 could walk by himself, would wander, and was very aggressive.
On 1/7/25 at 1530 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 verified Resident 8 was not diagnosed with psychosis in the acute care hospital prior to being admitted to the facility. RN 1 stated she was not sure where Resident 8's diagnosis of psychosis came from and could not provide documented evidence of when and who diagnosed Resident 8 with psychosis.
On 1/7/25 at 1629 hours, a concurrent interview and medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified she inputted Resident 8's medical diagnoses into their electronic medical records system. When asked where she found Resident 8's diagnosis of psychosis, the MDS stated she did not see a diagnosis of psychosis on Resident 8's medical record other than on Resident 8's physician's orders for the risperidone medication.
On 1/8/25 at 1439 hours, a concurrent interview and medical record review was conducted with the DON. The DON was informed of and acknowledged the above findings.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and servic...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 2) to help attain and maintain their highest practicable physical well-being.
* The facility failed to ensure Resident 2's Senna (stool softener), enoxaparin (anticoagulant medication), acetaminophen (analgesic), gabapentin (anticonvulsant and nerve pain medication) and nystatin suspension (antifungal medication) were administered as per the physician's order. This failure had the potential to negatively impact the resident's well-being.
Findings:
Review of facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner and as prescribed. If a drug is withheld, refused, or given at a time other than scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before the next ones.
Review of Resident 2's medical record was initiated on 11/8/24. Resident 2 was admitted to the facility on [DATE].
Review of Resident 2's MDS admission assessment dated [DATE], showed the resident's BIMS score of 14, indicating the resident's cognition was intact.
Review of Resident 2's physician's order for 10/10/24 to 11/08/24, showed the following orders:
- dated 10/17/24, Senna 8.6 mg one tablet by mouth at bedtime for bowel management (hold for loose stools).
- dated 10/10/24, enoxaparin sodium injection solution prefilled syringe 80 mg/0.8 ml subcutaneously every 12 hours for DVT.
- dated 10/17/24, acetaminophen 500 mg two tablets by mouth every eight hours for pain management, not to exceed 3 gm of APAP (same as acetaminophen) in 24 hours.
- dated 10/10/2024, gabapentin 300 mg one capsule by mouth three times a day for neuropathic (known as nerve pain, is a type of chronic pain caused by damage or disease to the nervous system) pain
- dated 10/10/24, Nystatin Suspension 100,000 unit/ml 5 ml (total of 500,000 units) by mouth swish and swallow four times a day for mouth fungal or yeast infection for 10 days
Review of Resident 2's MAR for October 2024 showed the following medications were not administered:
- on 10/20/24 at 2100 hours, Senna 8.6 mg one tablet by mouth at bedtime for bowel management (hold for loose stools).
- on 10/20/24 at 2100 hours, enoxaparin sodium injection solution prefilled syringe 80 mg/0. 8 ml subcutaneously every 12 hours for DVT.
- on 10/20/24 at 2200 hours, acetaminophen 500 mg two tablets by mouth every eight hours for pain management, not to exceed 3 gm of APAP in 24 hours.
- on 10/20/24 at 2200 hours, gabapentin 300 mg one capsule by mouth three times a day for neuropathic pain.
- on 10/20/24 at 2100 hours, Nystatin Suspension 100,000 unit/ml 5 ml (total of 500,000 units) by mouth swish and swallow four times a day for mouth fungal or yeast infection for 10 days.
Further review of the MAR failed to show documentation if the medications were held for any reason.
Further review of Resident 2's MAR showed Resident 2 had a pain level of 6 (on a 0 to 10 pain scale with 0 = no pain and 10 = worst pain) on 10/20/24 at 2300 hours. Resident 2 was given hydromorphone hydrochloride (opioid) 2 mg one tablet by mouth for moderate pain.
On 11/8/24 at 1028 hours, an interview was conducted with Resident 2. Resident 2 stated she did not receive her enoxaparin sodium injection and some other medications for pain for a couple of times. Resident 2 stated she notified a nurse and was told the medications were supposed to be given on time and the resident could not get the medication if beyond the scheduled time. Resident 2 further stated she suffered a lot of pain when she did not get her medications and had to ask for stronger pain medication.
On 11/8/24 at 1224 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified the above medications were not initialed in the MAR. The DON verified the above medications were not administered as ordered. The DON stated the medications were expected to be administered as ordered by the physician.
On 11/12/24 at 1320 hours, a telephone interview was conducted with LVN 3. LVN 3 stated she had very little time to give the medications. The medications might had been given but not documented. LVN 3 stated she could not prove the medications were given because they were not initialed in the MAR. LVN 3 further stated if the resident refused the medications, she would document of the resident's refusal and inform the RN supervisor or the desk nurse.
On 11/12/24 at 1414 hours, a telephone interview with LVN 4 was conducted. LVN 4 confirmed she worked as the desk nurse on 10/20/24. LVN 4 stated when she administered medication, she would pour the medications as scheduled, give the medications to the resident, then document the medications as administered. LVN 4 stated she did not receive any report on 10/20/24, that Resident 2 refused to take the medication.
On 11/12/24 at 1530 hours, an interview was conducted with the DON. The DON acknowledged the above medications were not initialed in the MAR. The DON stated the medication administration should be initialed on the MAR to show the medications were administered to the resident.
Oct 2024
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of 12...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of 12 sampled residents (Resident 8) attained and maintained the highest practicable physical well-being. This failure posed the risk for delayed care and intervention to Resident 8.
Findings:
Closed medical record review for Resident 8 was initiated on 10/10/24. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 8 was transferred to the acute care hospital on 9/29/24.
Review of Resident's Change in Condition Evaluation dated 9/27/24 at 2116 hours, showed at 1630 hours, a family member approached LVN 7 to check on Resident 8 because Resident 8's family member observed the resident with productive cough and appeared to be slightly weak.
Review of Resident 8's E-interact SBAR Summary for Providers dated 9/28/24, showed a CNA had reported the resident ate 0-25% of breakfast; and the family member reported the resident had been eating little for three days.
Review of Resident 8's MAR for September 2024 showed Resident 8 refused the following medications:
- on 9/28/24 at 1600 hours, acetylcysteine solution (a medication used to loosen and thin mucus in the lungs) 20% via mask.
- on 9/28/24 at 1600 hours, Baclofen (a medication used as skeletal muscle relaxant) 5 mg tablet by mouth.
- on 9/28/24 at 1600 hours, ipratropium bromide inhalation solution (a medication used to treat air flow blockage and prevent the worsening of chronic obstructive pulmonary disease) 0.02% 2.5. ml inhale by mouth.
- on 9/28/24 at 1700 hours, Marinol (a medication used to treat loss of appetite and weight loss) 5 mg capsule by mouth.
- on 9/28/24 at 1700 hours, Senna (a medication used on a short-term basis to treat constipation) 8.6 mg two tablets by mouth.
- on 9/28/24 at 1700 hours, rivaroxaban (a medication used to treat and prevent deep venous thrombosis (DVT, a condition in which harmful blood clots form in the blood vessels of the legs) 10 mg tablet by mouth.
Review of Resident 8's Oxygen Saturation Summary completed by the CNA showed 81% on 9/29/24 at 0024 hours (normal range: 95% and 100%).
Further review of Resident 8's medical record failed to show a care plan was initiated for the change in condition with productive cough and slightly weak on 9/27 and poor meal intake on 9/28/24. There was no documented evidence the resident was monitored every shift since the change in condition on 9/27/24 at 2116 hours. There was no documented evidence the CNA informed the charge nurse of the oxygen saturation level of 81%.
Review of Resident 8's Nurse's Notes dated 9/29/24 at 0240 hours, showed the charge nurse noted the resident was unresponsive, desaturating (decreasing oxygen saturation) and with abnormal vital signs. 911 was called and the physician and family member were notified.
On 10/11/24 at 0753 hours, an interview, and a concurrent record review with LVN 8 was conducted. LVN 8 verified Resident 8's oxygen saturation level on 9/29/24 at 0024 hours, showed 81%. LVN 8 stated CNA 3 did not inform her of the resident's oxygen saturation level of 81%. LVN 8 further stated she was not able to follow up with the CNA for the resident's oxygen saturation level results.
On 10/11/24 at 1050 hours, an interview with CNA 3 was conducted. CNA 3 confirmed she took Resident 8's oxygen saturation level at 81% on 9/29/24 at 0024 hours. CNA 3 stated she did not notify the charge nurse of the resident's oxygen saturation level because she did not think it was abnormal.
On 10/11/24 at 1115 hours, an interview with the DON was conducted. The DON stated she expected the nurses to monitor and document the resident's change of condition every shift for at least for 72 hours. The DON was made aware of the above findings
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary car...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injury (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for two of three sampled residents (Residents 8 and 11) reviewed for pressure injury.
* The facility failed to ensure Resident 8 was turned and repositioned at least every two hours as per the plan of care.
* The facility failed to ensure Resident 11's pressure ulcer was assessed weekly.
These failures posed Residents 8 and 11 at risk for developing new pressure ulcers and worsening of the existing pressure ulcer.
Findings:
1. Review of the facility's P&P titled Turning and Repositioning Schedule revised December 2023 showed it is the policy of the facility to ensure the safety and comfort of the residents through regular turning and repositioning to prevent pressure ulcer and promote skin integrity. The P&P showed the following:
* Turning schedule
High risk residents should be turned every 1-2 hours.
- 12 am/pm - Back
- 2 am/pm - Door
- 4 am/pm - Window
- 6 am/pm - Back
- 8 am/pm - Door
- 10 am/pm - Window
Medical record review for Resident 8 was initiated on 10/10/24. Resident 8 was admitted to the facility on [DATE].
Review of Resident 8's MDS 5 Day assessment dated [DATE], showed Section GG for the functional status showing Resident 8 required partial or moderate assistance in rolling left and right on the bed.
On 10/15/24 at 0926 hours, Resident 8 was observed lying on her right side turned facing the window.
On 10/15/24 at 1130 hours, Resident 8 was observed lying on her right side turned facing the window.
On 10/15/24 at 1452 hours, Resident 8 was observed lying on her right side turned facing the window.
On 10/15/24 at 1454 hours, an interview was conducted with CNA 2. CNA 2 verified resident was turned on right side. CNA 2 stated he would turn the resident now.
On 10/16/24 at 1630 hours, an interview was conducted with the DON. The DON stated the residents with pressure injury should be repositioned every two hours following the facility's schedule.
2. Medical record review for Resident 11 was initiated on 10/15/24. Resident 11 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident's 11 Comprehensive Skin Evaluation/assessment dated [DATE], showed Resident 11 was a new admit with a Stage 2 pressure ulcer at the coccyx, measuring 2 cm x 2 cm; and a Stage 3 pressure ulcer at the left buttock, measuring 5 cm and 3.5 cm.
Review of Resident 11's plan of care failed to show a care plan was developed to address the management of the resident's pressure ulcer to the coccyx and left buttocks.
Further review of Resident 11's Skin and Wound Evaluations failed to show an assessment was made after 9/19/24, until 10/11/24.
Review of Resident 11's Skin and Wound Evaluation dated 10/11/24, showed the resident's coccyx pressure ulcer was evaluated as follows: unable to determine stage, measuring 5.5 cm x 3.5 cm x 1 cm (depth), with 95% slough and 5% granulation with scant serosanguineous drainage.
On 10/16/24 at 1507 hours, an interview and concurrent medical record review with LVN 9 was conducted. LVN 9 verified Resident 11's pressure ulcer on the coccyx was a Stage 2 when resident was admitted . Currently, the resident's coccyx pressure ulcer stage was unable to determine. LVN 9 confirmed the pressure ulcer on the coccyx area was not assessed since readmission until 10/11/24.
On 10/16/24 at 1632 hours, an interview, and a concurrent record review was conducted with the DON. The DON verified the care plan was not developed and stated she expected weekly assessment of the wound should have been completed to assess the resident's wound for proper intervention.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections as evidenced by:
* The facility failed to ensure the EBPs (Enhanced Barrier Precautions) were followed for Resident 9 when the staff did not wear a disposable gown before providing care to the resident.
* The facility failed to ensure the hand hygiene was performed after using the gloves in between the dressing change.
These failures had the potential for spread of infections in the facility.
Findings:
Review of the facility's P&P titled Enhanced Barrier Precautions (EBP) revised august 2022 showed Enhanced Barrier Precautions are utilized to utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities.
Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:
a. dressing;
b. bathing/showering;
c. transferring;
d. providing hygiene;
e. changing linens;
f. changing briefs or assisting with toileting;
g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and
h. wound care (any skin opening requiring a dressing).
Medical record review for Resident 9 was initiated on 10/10/24. Resident 9 was admitted to the facility on [DATE].
On 10/10/24 at 1419 hours, an enhanced barrier precautions sign was observed posted outside Resident 9's room door alerting anyone entering the room to perform hand hygiene and don the gowns and gloves participating in any of the six moments of care:
- Morning and evening care,
- Toileting and changing of incontinent briefs
- Caring of devices and giving medical treatments
- Cleaning and disinfecting the environment
- Wound care
- Mobility assistance and preparing to leave the room
On 10/11/24 at 1128 hours, LVN 4 was observed with the wound consultant from the door of Resident 9's room performing wound treatment to Resident 9.
On 10/11/24 at 1130 hours, an interview was conducted with LVN 4. LVN 4 verified she just completed wound care to Resident 9. LVN 4 verified the resident had an EBP sign posted by the resident's wall by the head of the resident's bed. LVN 4 verified Resident 9 was on EBP and she and the wound consultant did not wear gown for the appropriate PPE.
On 10/11/24 at 1234 hours, an interview was conducted with the IP. The IP verified Resident 9 was on EBP. The IP was made aware of the findings.
On 10/16/24 at 0855 hours, a wound treatment observation with LVN 5 and CNA 2 was conducted for Resident 9's sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis). Resident 9 was on EBP. CNA 2 was at bedside turned the resident without a gown. LVN 5 was observed removing Resident 9's wound dressing without wearing a gown.
On 10/16/24 at 0856 hours, an interview was conducted with LVN 5. LVN 5 was asked if she was aware of Resident 9 on EBP. LVN 5 then stopped the wound care and washed hands and wear appropriate PPE with a gown. LVN 5 asked the CNA to wear a gown.
On 10/16/24 at 0905 hours, the wound care observation was continued for Resident 9's sacrum. with LVN 5 and CNA 2. LVN 5 changed gloves twice without washing hands in between while cleaning the resident's wound.
On 10/16/24 at 0924 hours, LVN 5 was observed to remove few gauzes on top of the unused gauze brought in the resident's room and returned unused gauze in the treatment cart. LVN 5 then cleansed the cap of the normal saline (a solution used to cleanse the wound) with the use of alcohol prep pads and returned the bottle of unused normal saline in the treatment cart.
On 10/16/24 at 0925 hours, an interview with LVN 5 was conducted. LVN 5 confirmed she returned the unused gauze in the treatment cart and cleansed only the cap of the normal saline and returned the bottle in the treatment cart. LVN 5 stated she should discard them. LVN 5 confirmed she did not wash her hands twice in between glove change during wound care.
On 10/16/24 at 1412 hours, an interview with the IP was conducted. The IP stated the licensed nurses and CNAs were made aware of the residents on EBP during shift endorsements and should wear appropriate PPE when performing high-contact resident care activities.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0558
(Tag F0558)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the accommodation of needs was met for one of 12 sampled resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the accommodation of needs was met for one of 12 sampled resident (Resident 12).
* The call light was not answered promptly for Residents 12. This failure had the potential for the resident not getting the needs met timely.
Findings:
Medical Record review for Resident 12 was initiated on 10/10/24. Resident 12 was admitted to the facility on [DATE].
Review of Resident 12's Quarterly Assessment MDS dated [DATE], showed Section B, the resident was able to make needs known, understood, and understand. Section C showed BIMS score of 15 (intact cognition). Section GG showed one side limitation in the range of motion of both upper and lower extremities.
On 10/10/24 at 1403 hours, the call light outside Room C was observed blinking from the hallway of Nursing Station A. The door of Room C was closed.
On 10/10/24 at 1414 hours, RN 1 was observed walking in the hallway and passing Room C twice. The RN did not respond to the call light.
On 10/10/24 at 1415 hours, an interview was conducted was conducted with RN 1. RN 1 verified he passed through Room C twice and did not respond to the call light. RN 1 stated he was going to another station.
On 10/10/24 at 1416 hours, the Activity Director was observed to go inside Room C and answered the call light. There were three residents in the room.
On 10/10/24 at 1428 hours, an interview with the Activity Director was conducted. The Activity Director stated Resident 12 put the call light on because the resident needed assistance to mark her clothes.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record was complete and accurate related...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record was complete and accurate related to oxygen saturation level, oxygen administration, and POLST for one of 12 sampled residents (Resident 8). This failure had the potential to negatively impact the delivery of services as the medical information was inaccurate.
Findings:
Closed medical record review for Resident 8 was initiated on 10/10/24. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 8 was transferred to an acute care hospital on 9/29/24.
1. Review of Resident 8's MAR (Medication Administration Record) for September 2024 showed to check the resident's oxygen saturation each shift. On 9/28/24 during the evening shift, the documented oxygen saturation level was 76%.
On 10/11/24 at 1515 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 stated the CNA took the resident's oxygen saturation at around 1700 hours on 9/28/24. The LVN further stated the CNA should have documented 96%.
On 10/11/24 at 1527 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.
2. Review of Resident 8's Interact SNF/NF to Hospital Transfer Form dated 9/29/24 completed at 0320 hours, showed the resident was provided with oxygen at 4 LPM.
Review of Resident 8's Nurse's Note late entry for 9/29/24 0230 hours, created 10/10/24 at 1844 hours, showed the resident was provided with supplemental oxygen via nonrebreather mask with high flow oxygen at 15 LPM.
Review of Resident 8's Order Summary as of 9/29/24, showed an order dated 6/13/24, for oxygen at 2 LPM via nasal cannula continuous per concentrator or tank.
Review of Resident 8's order summary failed to show a physician's order to administer oxygen at 4 LPM or oxygen at 15 LPM via non-rebreather mask.
On 10/10/24 at 1413 hours, an interview and concurrent closed medical record review was conducted with LVN 7. LVN 7 verified the Interact SNF/NF to Hospital Transfer Form dated 9/29/24 completed at 0320 hours, showed the resident was provided with oxygen at 4 LPM.
On 10/10/24 at 1610 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified Resident 8 was given oxygen at 4 LPM as documented in Interact SNF/NF to Hospital Transfer Form dated 9/29/24 completed at 0320 hours.
On 10/11/24 at 1008 hours, an interview with RN 3 was conducted. RN 3 verified she documented oxygen at 4 LPM in the Interact SNF/NF to Hospital Transfer Form on 9/29/24 completed at 0320 hours. RN 3 stated Resident 8 was given high flow supplemental oxygen at 15 LPM via non rebreathing mask on 9/29/24, as documented in her notes for late entry on 9/29/24 at 0230 hours. RN 3 stated she created the late entry on 10/10/24 at 1844 hours.
3. Review of Resident 8's POLST dated 6/14/24, showed the Section D advance directive available and reviewed was marked. The POLST form failed to show a signature of the resident or legally recognized decision maker, however, showed the verbal consent was obtained from a family member and was signed by two licensed nurses on the left side margin of the form.
Review of the resident's POLST dated 10/6/23, showed it was marked on Section D for no advance directives.
Review of Resident 8's medical record failed to show for an advance directive.
On 10/10/24 at 1443 hours, an interview and concurrent closed record review was conducted with LVN 7. LVN 7 verified there was no advanced directives in the electronic medical record of Resident 8.
On 10/11/24 at 1115 hours, an interview and concurrent record review was conducted with the Medical Records Director. The Medical Records Director verified Resident 8's electronic and paper medical record fail to show advance directive.
On 10/15/24 0830 hours, an interview and a concurrent record review was conducted with the Social Worker. The Social Worker stated the POLST completed on 10/6/23, should have been brought forward instead creating a new POLST when the resident was readmitted on [DATE].
Sept 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report an allegation of staff-to-resident abuse to the law enforcement agency, CDPH L&C Program, and Ombudsman office (an advocate for long term residents) for one of three sampled residents (Resident 1). This failure had the potential to put residents at risk for further abuse.
Findings:
Review of the facility's P&P titled Abuse Investigation and Reporting revised November 2017 showed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall promptly report to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.
Medical record review for Resident 1 was initiated on 9/17/24. Resident 1 was admitted to the facility on [DATE], with diagnosis of hemiplegia (paralysis in one side of the body) and hemiparesis (weakness or inability to move in one side of the body) affecting the right dominant side.
Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had a BIMS score of 10, indicating moderate cognitive impairment.
On 9/17/24 at 0946 hours, a telephone interview was conducted with the anonymous complainant. The anonymous complainant alleged CNA 1 abused Resident 1 on 9/3/24. According to the anonymous complainant, the incident was reported by Family Member 1 to the Administrator and DON.
On 9/17/24 at 1333 hours, an interview was conducted with the DON. The DON was asked regarding the allegation of abuse which occurred on 9/3/24, involving Resident 1 and CNA 1. The DON stated the incident was reported by the Activity Director on 9/3/24. Family Member 1 also reported the incident to the DON and Administrator. The DON confirmed no report was made to the CDPH L&C Program, law enforcement agency, and Ombudsman office regarding the incident. The DON confirmed the alleged abuse was not documented.
On 9/18/24 at 1022 hours, a telephone interview was conducted with Family Member 1. Resident 1 told Family Member 1 about the incident. Family Member 1 was asked how they identified the male staff who allegedly abused Resident 1. Family Member 1 stated when CNA 1 walked into Resident 1's room, Resident 1 got petrified and pointed to CNA 1. Family Member 1 informed the DON of the incident.
On 9/18/24 at 1508 hours, a telephone interview was conducted with MD 1. MD 1 stated the incident was told by Resident 1 on 9/3/24. MD 1 discussed the incident to the SSD and reported to the incident to the Administrator.
On 9/18/24 at 1525 hours, an interview was conducted with Resident 1. Resident 1 was asked about the incident which happened two weeks ago. Resident 1 became teary eyed and looked frightened. Resident 1 stated, They were very mean to me. Resident 1 was asked if it was a female staff, Resident 1 stated no. When asked if it was a male staff, Resident 1 nodded. Resident 1 demonstrated how the male staff covered Resident 1's mouth and further stated I am so scared.
On 9/20/24 at 1130 hours, the Administrator acknowledged above findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to implement their abuse P&P related to ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to implement their abuse P&P related to investigation of the physical abuse for one of three sampled residents (Resident 1).
* The facility failed to complete a thorough investigation including to conduct the interview of the person(s) reporting the incident, any witnesses to the incident, the resident, the staff members from different shifts and disciplines, resident's roommate if appropriate, family members, other residents to whom the accused employee provides care or services and report the result of the investigation to the CDPH L&C Program, Orange District Office within five working days. This failure posed the risk for the potential abuse to remain unidentified and for the residents to go unprotected.
Findings:
Review of the facility's P&P titled Abuse Investigation and Reporting revised November 2017 showed the individual conducting the investigation will, as a minimum, interview the person(s) reporting the incident, witnesses to the incident, the resident, staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, resident's roommate if appropriate, family members, and other residents to whom the accused employee provides care or services. The Administrator, his/her designee will provide the appropriate agencies or individuals listed above with a written repost of the findings of the investigation within five working days of the occurrence of the incident.
Medical record review for Resident 1 was initiated on 9/17/24. Resident 1 was admitted to the facility on [DATE], with diagnosis of hemiplegia and hemiparesis affecting the right dominant side.
On 9/17/24 at 0946 hours, a telephone interview was conducted with the anonymous complainant. The anonymous complainant alleged CNA 1 abused Resident 1 on 9/3/24. The incident was reported by Family Member 1 to the Administrator and DON.
On 9/17/24 at 1333 hours, an interview was conducted with the DON. The DON was asked about the allegation of abuse which occurred on 9/3/24, involving Resident 1 and CNA 1. The DON stated the incident was reported by the Activity Director on 9/3/24. Family Member 1 also reported the incident to the DON and Administrator. The DON was asked if an investigation was done. The DON stated only CNA 1, the alleged perpetrator was interviewed. The DON confirmed the alleged abuse was not documented.
On 9/20/24 at 1130 hours, the Administrator acknowledged above findings.
Cross reference to F609.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services related to foot care for one of three sampled residents (Resident 2).
* The facility failed to ensure the skin check, accurate assessment, and monitoring of Resident 2's bilateral feet after the podiatry care for fungal infection, including debridement and nail trimming.
This failure had the potential to negatively impact the resident's health and well-being.
Findings:
Review of the facility's P&P titled Charting and Documentation revised on 7/2017 showed all facility services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record: a. Objective observations b. Medications administered c. Treatments or services performed. d. Changes in the resident's condition e. Events, incidents or accidents involving the resident; and f. Progress toward changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective, complete, and accurate.
Review of the facility's P&P titled Care Plans, Comprehensive Person Centered revised 3/2022 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 11. Assessments of residents are ongoing and care plan are revised as information about the residents and the resident's condition change.
Medical record review for Resident 2 was initiated on 9/17/24. Resident 2 was admitted to the facility on [DATE].
Review of Resident 2's MDS Section C dated 9/12/24, showed Resident 2 had a BIMS score of 6, indicating severe cognitive impairment.
Review of Resident 2's MDS Section GG dated 9/12/24, showed Resident 2 needed partial assistance from another person to complete any activities as: self-care, indoor mobility (ambulation) and functional cognition.
Review of Resident 2's Order Summary Report dated 9/1/24-9/30/24, showed Resident 2's diagnosis included Type 2 Diabetes Mellitus with other specified complications.
Review of Resident 2's care plan dated initiated 7/14/24, showed a care plan problem addressing Resident 2 was at risk for altered skin integrity. The interventions included to monitor for any signs of skin breakdown (sore, tender, red, or broken areas).
Review of Resident 2's Convalescent Podiatry Care Evaluation & Treatment dated 8/19/24, showed Resident2's assessment/diagnosis included nail dystrophy and Tinea Unguium (a fungal infection of the nail that causes discoloration, thickening, and other changes to the nail), with evaluation of thickened, discolored, brittle with subungual debris and painful toenail(s) upon palpation on the right and left 1-5 toes. The treatment plan/procedure performed was debridement and trimming of nails utilizing nail [NAME] and Dremel of ten mycotic, hypertrophic, painful, incurvated toenails.
Further review of Resident 12's medical record failed to show documented evidence a care plan was developed to address the resident's fungal infection of the nail that resulted in debridement to be performed by the podiatrist. There was no documentation of the bilateral feet/toes skin assessment and monitoring of the debridement site or pain assessment related to the procedure on 8/19/24.
Review of Resident 2's SBAR Communication Form and Progress Note for RNs/LPN/LVNs dated 9/1/24 at 0923 hours, showed there was a change in condition, symptoms, or signs observed and evaluated on 9/1/24, and the condition symptom, or signs had not occurred before. The appearance/summarized observation and evaluation section of the SBAR showed it was reported by the CNA that the resident had swelling of the right foot and right second toe with slight redness and minimal drainage. The documentation showed the physician had ordered to transfer Resident 2 to the acute care hospital.
On 9/19/24 at 1327 hours, a concurrent interview and medical record review was conducted with the DON. The DON was asked to show any documentation of the monitoring of any skin breakdown and care plan for Resident 2's bilateral feet/toes since the last time Resident 2 received podiatry care and treatment on 8/19/24, with diagnosis of nail dystrophy and Tinea Unguium. The DON was not able to provide any documentation and verified there were no monitoring, assessment, and care plan for the bilateral feet/toes related to the procedure on 8/19/24.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided non-pharmacologic intervention for the use of psychotropic medication (medication that affects the mind, emotions, and behavior). This failure had the potential for Resident 1 to have adverse complications from the medication.
Findings:
Review of the facility's P&P titled Psychotropic Medication Use revised July 2022 showed non-pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.
Medical record review for Resident 1 was initiated on 9/17/24. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Order Summary Report for September 2024 showed a physician's order dated 7/11/24, to administer Lexapro oral 5 mg tablet by mouth one time a day for depression as manifested by tearful episodes.
Review of Resident 1's Progress Note dated 9/11/24, showed a new physician's order to increase the dose of Lexapro medication to 10 mg daily.
Review of Resident 1's Therapist Progress Note dated 9/19/24, showed a recent increase of Lexapro dosage due to tearful episodes with depression.
Review of Resident 1's MAR for August and September 2024 for the monitoring of the episodes of depression as evidenced by tearful crying showed the following:
- On 8/1/24, three episodes during the day shift and three episodes during the evening shift;
- On 8/7/24, three episodes during the day shift;
- On 8/20/24, one episode during each shift.
- On 8/21/24, three episodes during the day shift;
- On 8/22/24, four episodes during the evening shift;
- On 8/23/24, six episodes during the morning shift;
- On 8/25/24, five episodes during the morning shift and five episodes during the evening shift;
- On 8/27/24, four episodes during the evening shift;
- On 8/29/24, four episodes during the evening shift and three episodes during the night shift;
- On 8/30/24, four episodes during the day shift, six episodes during the evening shift, and six episodes during the night shift;
- On 8/31/24, six episodes during each shift.
- On 9/4/24, three episodes during the day shift;
- On 9/6/24, one episode during the evening shift;
- On 9/7/24, one episode during the day shift.
There was no documented evidence of any non-pharmacological interventions provided for Resident 1.
Further review of Resident 1's care plan problem addressing the use of Lexapro medication failed to show documentation of interventions for the non-pharmacological implementation for the use of the above medication.
On 9/20/24 at 0920 hours, a concurrent interview and medical record review was conducted with the DON. The DON stated Resident 1 received Lexapro daily in the morning and was monitored every shift for side effects and manifestation of tearfulness. The DON was unable to find any documentation for the non-pharmacological interventions provided when Resident 1 had episodes of tearfulness. The DON also verified there was no care plan for the non-pharmacologic interventions for the use of Lexapro medication.
Sept 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and service...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure injuries for three of six sampled residents (Residents 2, 4, and 5).
Findings:
* Resident 2's pressure injuries were not measured and assessed weekly. In addition, no pictures were taken as per the facility's protocol.
* Resident 2's low air loss mattress was set too high for Resident 2's weight.
* Resident 4's low air loss mattress was set too high for Resident 4's weight.
* Resident 5's low air loss mattress was set too high for Resident 5's weight.
These failures posed the risk for the residents to develop new pressure injuries and for existing pressure injuries to get worse.
Findings:
1. Review of the facility's P&P titled Prevention/Management of Pressure Ulcers/Injuries revised 12/2022 showed the following:
- to ensure weekly observation is completed and all changes are documented accordingly in the medical record; and
- for Stages 3, 4, UTD, and DTI pressure injuries, to utilize Skin and Wound module in PCC; and utilize photograph function in wound module for visual tracking and recording of wound progress and size until healed.
Medical record review for Resident 2 was initiated on 8/30/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 2's H&P examination dated 7/2/24, showed Resident 2 was bedbound and had multiple infected wounds. The H&P examination also showed Resident 2 had the capacity to make medical decisions.
Review of Resident 2's Nursing Comprehensive Skin Evaluation/assessment dated [DATE], showed Resident 2 had a Stage 4 pressure injury to the sacrum and right lateral knee; and unstageable pressure injury to the sacrum and right lateral knee; and unstageable pressure injury to the right and left ankles, left toe, right lateral upper foot, right lower lateral foot, and right heel.
Further review of Resident 2's medical record showed Resident 2 had been receiving the daily wound treatments as ordered by the physician. However, there was no documented evidence the weekly wound assessments including wound measurements and pictures were completed as per the facility's P&P. There were no weekly wound assessments done on Resident 2 between 7/22/24 and 9/2/24.
On 8/30/24 at 1115 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 stated he had several wounds on both legs, but the left leg was the worst and one part of the wound was still with discharges and he also had a wound at his bottom. Resident 2 further stated the nurses changed his wound dressing every day.
On 9/5/24 at 1445 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated she did the initial skin assessment for Resident 2 when he was admitted on [DATE]. LVN 3 stated the treatment nurse was responsible for the weekly wound assessments, including the wound description, size measurements, and photos; and must be documented. LVN 3 verified her last documented weekly wound assessment for Resident 2 was on 7/22/24, then she reassessed the resident's wound when she got back from her leave on 9/2/24.
On 9/6/24 at 1440 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and verified the above findings.
2. Review of the facility's P&P titled Beds, Special - Low Air Loss Therapy revised 9/2024 showed pressure adjustments for comfort may be made by the trained facility staff in accordance with the resident condition and need.
Review of the Comfort Level Reference Chart for the low air loss mattress located at the side of the machine showed the level is to be determined by the resident's weight distribution. The label showed the weight and corresponding setting for comfort level. For the residents weighing 75 lbs = 3.5-4, 100 lbs = 4, 125 lbs = 4.5, 150 lbs = 5, 175 lbs = 5-6, 200 lbs = 6-7, 250 lbs = 7-8, 300 lbs = 8-9, 350 lbs = 9, and 400 lbs = 10.
a. Medical record review for Resident 2 was initiated on 8/30/24. Resident 2 was readmitted to the facility on [DATE].
Review of Resident 2's H&P examination dated 7/2/24, showed Resident 2 had a history of being bedbound and multiple pressure ulcers. The H&P also showed Resident 2 had the capacity to make medical decisions.
Review of Resident 2's Order Summary Report showed a physician's order dated 7/14/24, to provide a pressure reducing mattress.
Review of Resident 2's Monthly Weight Report for August and September 2024 showed Resident 2 weighed 173 lbs in August and 166 lbs in September.
On 9/5/24 at 0900 hours, an interview and concurrent observation was conducted with LVN 3. Resident 2 was observed lying on his back on a low air loss mattress. The control panel for the low air loss mattress indicated the comfort level setting was set to levels 8-9. LVN 3 stated according to the weight guidelines for the low air loss mattress, Resident 2's mattress comfort level setting should have been set to levels 5-6. LVN 3 stated the low air loss mattress was set 125 lbs higher than it should have been. LVN 3 stated the low air loss mattress was set too firm for Resident 2's weight, which would put more pressure on areas of Resident 2's body. LVN 3 stated the purpose of the low air loss mattress was to prevent pressure points on Resident 2's body by circulating air flow. LVN 3 stated the firmer mattress was putting pressure on Resident 2's sacral area.
b. Medical record review for Resident 4 was initiated on 9/9/24. Resident 4 was admitted to the facility on [DATE].
Review of Resident 4's H&P examination dated 7/2/24, showed Resident 4 had a Stage 3 pressure injury to her upper back. The H&P examination also showed Resident 4 did not have the capacity to make medical decisions.
Review of Resident 4's Order Summary Report showed a physician's order dated 8/31/24, to provide a pressure reducing mattress.
Review of Resident 4's Monthly Weight Report for August 2024 showed Resident 4 weighed 182.1 lbs.
On 9/5/24 at 1255 hours, a concurrent interview and observation was conducted with RN 2. Resident 4's low air loss mattress setting was observed to be set at a comfort level of 7-8. RN 2 checked the mattress Comfort Level Reference Chart and stated levels 7-8 would be for a patient who weighed 250 lbs. RN 2 acknowledged Resident 4 did not look like she weighed 250 lbs.
c. Medical record review for Resident 5 was initiated on 9/5/24. Resident 5 was admitted to the facility on [DATE].
Review of Resident 5's H&P examination dated 11/21/23, showed Resident 5 had a diagnosis of quadriplegia.
Review of Resident 5's Order Summary Report showed a physician's order dated 11/3/22, to provide low air loss mattress for skin management and to set according to the resident's weight every shift for skin management.
Review of Resident 5's Care Plan showed a care plan problem initiated on 5/31/22, addressing Resident 5's high risk for altered skin integrity. The interventions included low air loss mattress as ordered.
Review of Resident 5's Monthly Weight Report for August and September 2024 showed Resident 5 weighed 160 lbs. in August and 165.4 lbs. in September.
On 9/5/24 at 1255 hours, a concurrent interview and observation was conducted with RN 2. Resident 5 was observed lying on a low air loss mattress. Resident 5's low air loss mattress was set at levels of 7-8. Review of the mattress Comfort Level Reference Chart indicated a comfort level of 7-8 was for a person who weighed 250 lbs. On the top of Resident 5's mattress control panel had a handwritten label showing 5-6. RN 2 stated he did not realize the label indicated what the comfort level settings were supposed to be at and confirmed the settings were too firm for Resident 5.
On 9/9/24 at 1450 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement and maintain their infection control program for two of six sampled residents (Residents 2 and 6) as evidenced by:
* LVN 1 failed to wear a disposable gown as required for EBP prior to performing the wound care to Resident 2.
* LVN 1 failed to establish a clean field to place the clean and sterile wound supplies for Resident 2.
* LVN 3 failed to wear a disposable gown as indicated for EBP while performing wound care and to establish a clean field to place the wound supplies while performing wound care for Resident 2.
* CNA 1 failed to wear a disposable gown as indicated for EBP during transfer and repositioning of a resident.
These failures have the potential risk of transmission of disease-causing microorganisms and infections to the residents.
Findings:
Review of the facility's P&P titled Enhanced Barrier Precautions revised 8/2022 showed the following:
- Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents.
- EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.
- EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room); and
- Examples of high contact resident care activities requiring the use of gown and gloves for EBPs included wound care (any skin opening requiring a dressing), bathing, showering, and transferring.
Review of the facility's P&P titled Wound Care, (undated), under the section for Steps in the Procedure showed the following:
- use of a disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached,
- be certain all clean items are on the clean field,
- use clean field saturated with alcohol to wipe overbed table,
- return the overbed table to its proper position,
- wipe reusable supplies with alcohol as indicated. Return supplies to resident's drawer in the treatment cart, and
- take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart.
1. Medical record review for Resident 2 was initiated on 8/30/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 2's H&P examination dated 7/2/24, showed Resident 2 was bedbound and had multiple infected wounds. The H&P examination also showed Resident 2 had the capacity to make medical decisions.
Review of Resident 2's Order Summary Report dated August 2024 showed the physician's orders for the following:
- on 7/15/24, for isolation with EBP related to wounds/midlines and may cohort every shift;
- on 8/23/24, for the left lateral lower leg vascular wound to be cleansed with normal saline, pat dry, apply Santyl collagen (for wound debridement) and abdominal pad, and wrap with kerlix every day shift for wound care for 30 days;
- on 8/23/24, for the left lateral malleolus vascular wound to be cleansed with normal saline; pat dry; apply collagen, calcium alginate (a water-insoluble, gelatinous, cream-colored substance for wound care), and abdominal pad; then wrap with kerlix every day shift for wound care for 30 days;
- on 8/23/24, for the right lateral foot UTD pressure injury to be cleansed with normal saline, pat dry, apply Santyl collagen and abdominal pad, then wrap with kerlix every day shift for wound care for 30 days;
- on 8/23/24, for the right lateral foot vascular wound to be cleansed with normal saline, pat dry, apply collagen and abdominal pad, then wrap with kerlix every day shift for wound care for 30 days;
- on 8/23/24, for the right lateral lower leg inferior vascular wound to be cleansed with normal saline; pat dry; apply Santyl collagen, calcium alginate, and abdominal pad; then wrap with kerlix every day shift for wound care for 30 days;
- on 8/23/24, for the right lateral malleolus vascular wound to be cleansed with normal saline; pat dry; apply Santyl collagen, calcium alginate, and abdominal pad; then wrap with kerlix every day shift for wound care for 30 days; and
- on 8/26/24, for the Stage 4 sacrum pressure injury to be cleansed with normal saline, pat dry, apply Medi-honey (to treat wound infection, or reducing bacteria level) and calcium alginate, and cover with a foam dressing every day shift for wound care healing for 14 days.
a. On 8/30/24 at 1115 hours, an observation and concurrent interview was conducted with Resident 2. A door signage for EBP was observed posted on the wall outside Resident 2's door and a storage organizer was observed on the wall in front of Resident 2's bed containing disposable gowns, gloves, and masks. An EBP signage was also observed posted on the wall by Resident 2's head part of the bed. Resident 2 was asked if he had wounds, Resident 2 stated he had several wounds on both legs, but the left leg was the worst, and one area was still with discharges, and he also had a wound at his bottom. Resident 2 further stated the nurses changed his wound dressing every day.
On 9/4/24 at 1150 hours, a wound care observation for Resident 2 was conducted with LVN 1.
LVN 1 was observed placing a clear plastic bag underneath Resident 2's left leg and foot with gloves on, then proceeded to remove the old dressings from the left foot and leg and placed the soiled dressings in the plastic bag. LVN 1 doffed her gloves, performed hand hygiene, and donned new gloves and proceeded with the wound care on the left lateral lower leg. The left lateral lower leg wound was observed draining with light red color of drainage and LVN 1 was observed not wearing a disposable gown. After LVN 1 applied a dry dressing to cover Resident 2's wound, LVN 1 doffed her gloves, performed hand hygiene, and proceeded to wear a disposable gown to continue with the rest of Resident 2's wound care treatment to both legs and sacrum. LVN 1 stated she usually did not wear the gown because she got allergic reactions at times. When asked if LVN 1 told her supervisors or the management about it, LVN 1 did not respond.
On 9/4/24 at 1420 hours, an interview with LVN 1 was conducted. LVN 1 was observed without any signs and symptoms of allergic reaction from wearing the disposable gown during the wound care. LVN 1 was informed of the observations during wound care treatment for Resident 2. LVN 1 stated the EBP signage outside the resident's door indicated the staff had to wear both gloves and gown when doing wound care. LVN 1 acknowledged the above findings and stated she missed donning a gown prior to performing the wound care treatment for Resident 2.
On 9/4/24 at 1535 hours, an interview was conducted with the IP. The IP stated the facility staff were expected to always follow the EBP precautions when doing high contact resident activities like wound care to prevent cross contamination and the spread of bacteria or infection between the residents as well as to the staff. The IP was informed and acknowledged the above findings.
b. On 9/4/24 at 1150 hours, a wound care observation for Resident 2 was conducted with LVN 1. LVN 1 was observed preparing all the wound care supplies to be used for Resident 2's wound care treatment. LVN 1 placed the sealed disposable dry gauze, kerlix wrap, foam dressings, disposable wooden spatulas, tape, normal saline, and wound ointments in medicine cups inside a blue plastic box container. LVN 1 walked to Resident 2's bedside and placed the blue container containing the wound care supplies directly to Resident 2's bed and proceeded with the wound care. LVN 1 was observed taking some wound care supplies out of the blue container and putting it directly on top of Resident 2's bedsheet including the gauze, kerlix, and wound ointment. The blue container was on Resident 2's bed throughout the wound care treatment. After the wound care treatment was completed, LVN 1 was observed placing the blue container with some of the unused wound care supplies on top of the treatment cart without cleaning the blue container, then LVN 1 proceeded to put the treatment cart in the hallway and headed to the nurse's station.
On 9/4/24 at 1420 hours, LVN 1 was informed of the observations during wound care treatment for Resident 2. LVN 1 stated she did not want to use the overbed table because Resident 2 was using it for eating. LVN 1 acknowledged she could have placed a clean drape on it but missed it. LVN 1 stated she wiped and sanitized the treatment cart at the end of her shift and sometimes she would just throw the containers when heavily soiled. LVN 1 stated she threw the blue container she used as well as the supplies not used. LVN 1 further stated she did not wipe the top of the treatment cart yet, but she would do it now.
On 9/4/24 at 1535 hours, an interview was conducted with the IP. The IP stated the practice during wound care was to use the overbed table as indicated in the facility's policy. The nurse could get an extra overbed table to use if the overbed table at the resident's room was occupied with the resident's belongings. The IP further stated any reusable supplies including the outsides of the containers that were touched by unclean hands should be wiped with alcohol prior to returning in the treatment cart. The IP stated the staff were expected to always observe proper infection control measures to prevent cross contamination and spread of bacteria or infection. The IP was informed and acknowledged the above findings.
c. On 9/5/24 at 0900 hours, an interview and concurrent observation was conducted with LVN 3. LVN 3 was observed at Resident 2's bedside picking up bloody gauze and used tape from the top of Resident 2's bed cover then putting the contaminated items into a garbage bag. An EBP signage was observed posted on the wall above Resident 2's bed. LVN 3 was observed not wearing a disposable gown. LVN 3 stated she just finished the dressing change on Resident 2. LVN 3 stated she performed wound care on Resident 2's legs and lower back. LVN 3 stated she did not wear a disposable gown during the wound dressing change procedure for Resident 2. LVN 3 stated she should have been wearing a gown. When LVN 3 was asked why Resident 2 was on EBP precautions. LVN 3 stated it was because Resident 2 had open wounds and a urinary catheter. Resident 2's bedside table was observed with Resident 2's personal items on it. LVN 3 stated she did not use the bedside table for the dressing supplies. When LVN 3 was asked why she did not use the bedside table, LVN 3 stated she put the supplies on the bed, but it had a sheet under them. LVN 3 stated the bedside table was supposed to be used for dressing changes, but Resident 2 had his personal items on it.
2. Medical record review for Resident 6 was initiated on 9/5/24. Resident 6 was admitted to the facility on [DATE].
Review of Resident 6's H&P examination dated 6/4/24, showed Resident 6 had the capacity to understand and make medical decisions. Resident 6 had diagnoses of pressure injury to the sacrum and incisions to both legs.
Review of Resident 6's Order Summary Report showed an order dated 6/3/24, for isolation with EBP related to indwelling urinary catheter and wounds.
On 9/5/24 at 1048 hours, a concurrent interview and observation was conducted with CNA 1. CNA 1 and Student 1 were observed wheeling Resident 6 down the hall into Resident 6's room, on a shower chair. CNA 1 and Student 1 were not wearing disposable gowns. CNA 1 and Student 1 had assisted Resident 6 from the shower chair and into his bed. An EBP signage was observed posted on the wall above Resident 6's bed. CNA 1 stated they should have been wearing the disposable gowns.
On 9/5/24 at 1351 hours, an interview was conducted with the IP. The IP was informed about the observation regarding the care of Resident 6 as he returned from his shower. The IP stated the staff should wear disposable gowns when showering, transferring, or assisting a resident who was on EBP.
Jul 2024
1 deficiency
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Infection Control
(Tag F0880)
Minor procedural issue · This affected multiple residents
Based on observation, interview and facility P&P review, the facility failed to ensure the infection control practices were maintained.
* LVN 1 failed to perform hand hygiene after administering an ey...
Read full inspector narrative →
Based on observation, interview and facility P&P review, the facility failed to ensure the infection control practices were maintained.
* LVN 1 failed to perform hand hygiene after administering an eyedrop medication to Resident 2. This failure had the potential to result in the spread of infection to the residents.
Findings:
Review of the facility's P&P titled Handwashing/ Hand Hygiene Policy revised 8/2019 showed the facility considers hand hygiene is the primary means to prevent infection. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents; before preparing or handling medications, before donning sterile gloves, after contact with objects (e.g. medical equipment), after removing gloves, after contact with blood or bodily fluids.
On 7/19/24 at 0844 hours, an observation and concurrent interview was conducted with LVN 1 during the medication administration. LVN 1 administered Timolol Maleate Solution 0.5% (an eyedrop medication) to Resident 2, removed the gloves, and threw them into the trash. LVN 1 failed to perform hand hygiene after administering the medication. LVN 1 then proceeded to touch the medication cart surface and work on the laptop. LVN 1 verified she failed to perform hand hygiene after administering the medication.
On 7/22/24 at 1331 hours, an interview was conducted with the DON. The DON verified LVN 1 should have performed hand hygiene after removing her gloves.
May 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the adequate supervision and ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the adequate supervision and necessary services for one of two sampled residents (Resident 1) to prevent the elopement.
* The facility failed to monitor Resident 1's whereabouts, resulting in Resident 1 leaving the facility undetected and sustaining a fall.
* The facility failed to notify Resident 1's responsible party of Resident 1's episodes of elopement and fall.
These failures had the potential to negatively impact the resident's well-being.
Findings:
Review of the facility's P&P titled Elopements revised December 2007 showed the staff shall investigate and report all cases of missing residents. If an employee discovers that a resident is missing from the facility, he/she shall notify the resident's legal representative.
Review of the facility's P&P titled Change of Condition in a Resident's Condition or Status, undated, showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., in level of care, billing/payments, resident rights, tec.) and unless otherwise instructed by the resident, a nurse will notify the resident's representative when:
a. the resident is involved in any accident or incident that resulted in an injury including injuries of an unknown source;
b. there is significant change in the resident's physical, mental, or psychosocial status;
c. there is a need to change the resident's room assignment;
d. a decision has been made to discharge the resident from the facility; and or
e. it is necessary to transfer the resident to a hospital/treatment center.
Medical record review for Resident 1 was initiated on 5/8/24. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Change in Condition Evaluation dated 3/24/24, showed Resident 1 was found outside, in front of the facility in his wheelchair. Resident 1 was redirected by the staff to go back in the facility.
Review of Resident 1's Elopement Risk assessment dated [DATE], showed Resident 1 had made one or more attempts of elopement in the last year and had voiced the desire to leave.
Review of Resident 1's Care Plan initiated on 3/24/24, showed the following:
- a care plan problem addressing Resident 1's risk for elopement/exit seeking related to altered cognitive status, dementia, exit seeking behaviors and forgetfulness;
- the goals included for the resident's safety, not being endangered related to the behaviors, not leaving the facility without a responsible person, and not wandering out of the facility; and
- the interventions included to assess for placement in a specially designed therapeutic unit as indicated and check for the door alarms promptly to ensure safety.
Review of Resident 1's MDS dated [DATE], showed Resident 1 had moderate cognitive impairment.
Review of Resident 1's Progress Note dated 4/30/24 at 0835 hours, showed a call was received from Fire Department A regarding Resident 1 being found on the ground on a sidewalk. The nurse's note showed according to Fire Department A, Resident 1 stated he was sitting in the patio and asked for a ride to go to church. The person provided Resident 1 a ride and dropped him off at the church. The nurse's note further showed after the rider had left, Resident 1 fell, and the EMS transported Resident 1 to the acute care hospital.
Review of Resident 1's SBAR form dated 4/30/24, showed Resident 1 was brought to Acute Hospital A after sustaining a fall outside of the facility.
Further review of Resident 1's medical record showed Resident 1 was brought back to the facility later that day on 4/30/24.
On 5/8/24 at 0815 hours, an interview was conducted with Resident 1's responsible party. The responsible party stated he was called and notified by Acute Hospital A of Resident 1's admission due to a fall outside the church. The responsible party further stated the facility did not notify him of Resident 1's elopement and fall.
On 5/8/24 at 1020 hours, an interview was conducted with RN 1. RN 1 verified Resident 1 left the facility without staff knowledge and had sustained a fall with no injury outside the facility. RN 1 stated she did not contact the resident's responsible party regarding Resident 1's elopement and fall.
On 5/8/24 at 1045 hours, an interview was conducted with LVN 1. LVN 1 stated she received a call from Fire Department A stating Resident 1 was found on the sidewalk outside of the facility and had sustained a fall with no injury and would be taken to Acute Hospital A for evaluation. LVN 1 stated she did not contact resident's responsible party regarding Resident 1's elopement and fall.
On 5/13/24 at 1200 hours, an interview was conducted with the DON. The DON verified Resident 1 had eloped from the facility without the staff knowledge and sustained a fall. The DON further stated she did not know how Resident 1 was able to get a ride from a person other than his assigned transportation. The DON verified Resident 1's responsible party was not notified and should have been notified by the staff.
Based on interview, medical record review, and facility P&P review, the facility failed to provide the adequate supervision and necessary services for one of two sampled residents (Resident 1) to prevent the elopement.
* The facility failed to monitor Resident 1's whereabouts, resulting in Resident 1 leaving the facility undetected and sustaining a fall.
* The facility failed to notify Resident 1's responsible party of Resident 1's episodes of elopement and fall.
Thesefailures had the potential to negatively impact the resident's well-being.
Findings:
Review of the facility's P&P titled Elopements revised December 2007 showed the staff shall investigate and report all cases of missing residents. If an employee discovers that a resident is missing from the facility, he/she shall notify the resident's legal representative.
Review of the facility's P&P titled Change of Condition in a Resident's Condition or Status, undated, showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., in level of care, billing/payments, resident rights, tec.) and unless otherwise instructed by the resident, a nurse will notify the resident's representative when:
a. the resident is involved in any accident or incident that resulted in an injury including injuries of an unknown source;
b. there is significant change in the resident's physical, mental, or psychosocial status;
c. there is a need to change the resident's room assignment;
d. a decision has been made to discharge the resident from the facility; and or
e. it is necessary to transfer the resident to a hospital/treatment center.
Medical record review for Resident 1 was initiated on 5/8/24. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Change in Condition Evaluation dated 3/24/24, showed Resident 1 was found outside, in front of the facility in his wheelchair. Resident 1 was redirected by the staff to go back in the facility.
Review of Resident 1's Elopement Risk assessment dated [DATE], showed Resident 1 hadmade one or more attempts of elopement in the last year and had voiced the desire to leave.
Review of Resident 1's Care Plan initiated on 3/24/24, showed the following:
- a care plan problem addressing Resident 1's risk for elopement/exit seeking related to altered cognitive status, dementia, exit seeking behaviors and forgetfulness;
- the goals included for the resident's safety, not being endangered related to the behaviors, not leaving the facility without a responsible person, and not wandering out of the facility; and
- the interventions included to assess for placement in a specially designed therapeutic unit as indicated and check for the door alarms promptly to ensure safety.
Review of Resident 1's MDS dated [DATE], showed Resident 1 had moderate cognitive impairment.
Review of Resident 1's Progress Note dated 4/30/24 at 0835 hours, showed a call was received from Fire Department A regarding Resident 1 being found on the ground on a sidewalk. The nurse's note showed according to Fire Department A, Resident 1 stated he was sitting in the patio and asked for a ride to go to church. The person provided Resident 1 a ride and dropped him off at the church. The nurse's note further showed after the rider had left, Resident 1 fell, and the EMS transported Resident 1 to the acute care hospital.
Review of Resident 1's SBAR form dated 4/30/24, showed Resident 1 was brought to Acute Hospital A after sustaining a fall outside of the facility.
Further review of Resident 1's medical record showed Resident 1 was brought back to the facility later that day on 4/30/24.
On 5/8/24 at 0815 hours, an interview was conducted with Resident 1's responsible party. The responsible party stated he was called and notified by Acute Hospital A of Resident 1's admission due to a fall outside the church. The responsible party further stated the facility did not notify him of Resident 1's elopement and fall.
On 5/8/24 at 1020 hours, an interview was conducted with RN 1. RN 1 verified Resident 1 left the facility without staff knowledge and had sustained a fall with no injury outside the facility. RN 1 stated she did not contact the resident's responsible party regarding Resident 1's elopement and fall.
On 5/8/24 at 1045 hours, an interview was conducted with LVN 1. LVN 1 stated she received a call from Fire Department A stating Resident 1 was found on the sidewalk outside of the facility and had sustained a fall with no injury and would be taken to Acute Hospital A for evaluation. LVN 1 stated she did not contact resident's responsible party regarding Resident 1's elopement and fall.
On 5/13/24 at 1200 hours, an interview was conducted with the DON. The DON verified Resident 1 had eloped from the facility without the staff knowledge and sustained a fall. The DON further stated she did not know how Resident 1 was able to get a ride from a person other than his assigned transportation. The DON verified Resident 1's responsible party was not notified and should have been notified by the staff.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record for one of two sampled residents ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record for one of two sampled residents (Resident 1) was accurate and complete.
* The facility failed to ensure Resident 1's MDS was accurate. This failure had the potential for the resident's care needs not being met as their medical information was inaccurate and incomplete.
Findings:
Medical record review for Resident 1 was initiated on 5/8/24. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Change in Condition Evaluation dated 3/24/24, showed Resident 1 was found outside, in front of the facility in his wheelchair. Resident 1 was redirected to go inside the facility.
Review of Resident 1's Elopement Risk assessment dated [DATE], showed Resident 1 had made one or more attempts of elopement in the last year and has voiced the desire to leave.
Review of Resident 1's Care Plan initiated on 3/24/24, showed a care plan problem addressing
Resident 1's risk for elopement and exit seeking related to altered cognitive status, dementia, exit seeking behaviors and forgetfulness and the goals included were resident's safety, will not be endangered related to the behaviors, will not leave the facility without a responsible person, and will not be wandering out of the facility.
Review of Resident 1's MDS Section E Behavior - Wandering Presence & Frequency dated 3/27/24, shows the following:
- wandering behavior not exhibited; and
- under the question, does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., outside of the facility), showed a blank entry.
On 5/13/24 at 1200 hours, an interview was conducted with the DON. The DON verified the above findings and stated the MDS information was inaccurate, and Resident 1 should have been coded as wanderer.
Based on interview and medical record review, the facility failed to ensure the medical record for one of two sampled residents (Resident 1) was accurate and complete.
* The facility failed to ensure Resident 1's MDS was accurate. This failure had the potential for the resident's care needs not being met as their medical information was inaccurate and incomplete.
Findings:
Medical record review for Resident 1 was initiated on 5/8/24. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Change in Condition Evaluation dated 3/24/24, showed Resident 1 was found outside, in front of the facility in his wheelchair. Resident 1 was redirected to go inside the facility.
Review of Resident 1's Elopement Risk assessment dated [DATE], showed Resident 1 hadmade one or more attempts of elopement in the last year and has voiced the desire to leave.
Review of Resident 1's Care Plan initiated on 3/24/24, showed a care plan problem addressing
Resident 1's risk for elopement and exit seeking related to altered cognitive status, dementia, exit seeking behaviors and forgetfulness and the goals included were resident's safety, will not be endangered related to the behaviors, will not leave the facility without a responsible person, and will not be wandering out of the facility.
Review of Resident 1's MDS Section E Behavior – Wandering Presence & Frequency dated 3/27/24, shows the following:
- wandering behavior not exhibited; and
- under the question, does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., outside of the facility), showed a blank entry.
On 5/13/24 at 1200 hours, an interview was conducted with the DON. The DON verified the above findings and stated the MDS information was inaccurate, and Resident 1 should have been coded as wanderer.
Nov 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure Resident 1 w...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure Resident 1 was free from the physical abuse when Resident 2 hit Resident 1 across the face, causing Resident 1 to have a bloody nose and a skin tear to the left forearm. This failure had the potential for not protecting the resident and negatively impact the resident's well-being.
Findings:
Review of the facility's 5-day Investigation Summary dated 10/29/23, showed on 10/28/23 at approximately 0630 hours, Resident 2 hit Resident 1 across the face because Resident 1 was sitting in Resident 2's wheelchair and would not get out of it. Resident 1 suffered a bloody nose and a left forearm skin tear.
1. Medical record review was initiated for Resident 1 on 11/7/23. Resident 1 was admitted to the facility on [DATE], and had diagnoses including dementia.
Review of Resident 1's History and Physical examination dated 8/21/23, showed Resident 1 did not have the capacity to understand or make medical decisions.
Review of Resident 1's MDS dated [DATE], showed Resident 1 had severe cognitive impairment.
Review of Resident 1's Progress Notes dated 10/28/23, showed an incident occurred between Residents 1 and 2. Resident 2 hit Resident 1 in the face.
Review of Resident 1's Discharge Skin assessment dated [DATE],showed Resident 1 had a skin tear to the left forearm and a mark under the left eye.
2. Medical record review was initiated for Resident 2 on 11/7/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 2's History and Physical examination dated 10/11/23, showed Resident 2 did not have the capacity to understand or make medical decisions.
Review of Resident 2's MDS dated [DATE], showed Resident 2 had severe cognitive impairment.
Review of Resident 2's Progress Notes dated 10/28/23, showed at approximately 0645 hours, Resident 2 had an argument with Resident 1. According to Resident 2, Resident 1 sat in his wheelchair and Resident 2 told Resident 1 to get up from his wheelchair multiple times and Resident 1 did not listen. Resident 2 stated he hit Resident 1 once across the face. Resident 2 added Resident 1 tried to punch him back but Resident 1 missed. The document further showed CNA 3 heard yelling and saw Residents 1 and 2 fighting each other. CNA 3 went in between Residents 1 and 2 and separated them. CNA 3 then notified a charge nurse.
On 11/8/23 at 1402 hours an interview was conducted with Resident 2. When Resident 2 was asked why he was moved to a different room, he stated he had hit someone. Resident 2 stated this was his chair, and he told Resident 1 to get out as he was going someplace.
Review of CNA 3's witness statement showed on 10/28/23, CNA 3 witnessed Residents 1 and 2 throwing their hands at each other's faces. Resident 1 was already bleeding from the nose. CNA 3 removed Resident 1 from the situation and informed LVN 5.
On 11/9/23 at 1040 hours, an interview was conducted with LVN 5. LVN 5 stated on 10/28/23 at about 0645 hours, in the morning, CNA 3 wheeled Resident 1 to the nurse's station. Resident 1 had a bloody nose. LVN 5 stated she cleaned up the blood and applied an ice pack to Resident 1's nose. LVN 5 stated she asked Resident 1 what happened, and Resident 1 stated his roommate hit him. LVN 5 stated sheasked Resident 2 why he hit Resident 1, and Resident 2 stated he hit Resident 1 because Resident 1 was in his wheelchair. LVN 5 stated prior to this incident, Resident 1 would take things from Resident 2's closet, and Resident 2 would call staff to let them know about it.
On 11/7/23 at 1307 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 1 liked to take other people's things and would take Resident 2's belongings. CNA 1 stated when Resident 1 took Resident 2's belongings, Resident 2 would let her know and she would return the items. CNA 1 stated she never saw Resident 2 get mad.
On 11/13/23 at 1645 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 1 would take Resident 2's property like a cap or a chair. Resident 2 was defensive about his property and would politely tell Resident 1 that it was not Resident 1's property. CNA 2 stated Resident 2 did not exhibit signs of aggression but would say he was upset about Resident 1 taking his property.
On 11/9/23 at 1230 hours, during an interview with the DON, the DON stated during the investigation of Residents 1 and 2's physical altercation, she was informed Resident 1 would take other people's things and the staff would redirect him. The DON stated after this incident, a care plan was developed regarding Resident 1's behavior of going through other people's things. The DON stated during the interview with Resident 2's family, Resident 2's family confirmed Resident 1 would get confused and go through Resident 2's things. The DON also stated Resident 2's family had informed her that Resident 2 had expressed frustration over Resident 1 being in his wheelchair.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure one of three...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure one of three sampled residents' (Resident 3) medication was administered as ordered by the physician. This failure had the potential to affect Resident 3's physical well-being.
Findings
Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in accordance with theprescriber's orders including any required time frame. The policy also showed medication times are determined by resident need and benefit including enhancing the optimal therapeutic effect of the medication, preventing potential food interactions, and honoring resident preferences.
According to the Promacta website, Promacta is used for the treatment of thrombocytopenia (a condition that occurs when the platelet count in blood is too low) and should be taken at the same time each day.
Medical record review for Resident 3 was initiated on 11/7/23. Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included thrombocytopenia and ESRD receiving hemodialysis.
Review of Resident 3's History and Physical examination dated 10/11/23, showed Resident 3 was able to understand and make medical decisions.
Review of Resident 3's MDS dated [DATE], showed Resident 3 was cognitively intact.
Review of Resident 3's Order Summary Report showed a physician's order dated 10/18/23, to administer Promacta 50 mg (Eltrombopag Olamine) one tablet by mouth in the morning for thrombocytopenia/anemia.
Resident 3's MAR for October 2023 showed Promacta 50 mg was scheduled to be given at time 0600 hours daily. Further review of the MAR showed on 10/21/23, Resident 3 was administered Promacta by LVN 7.
On 11/9/23 at 1525 hours, a telephone interview was conducted with LVN 7. LVN 7 verified he took care of Resident 3 on 10/21/23. LVN 7 stated he could not locate Resident 3's Promacta medication in the morning of 10/21/23. LVN 7 added he had already signed the medication off as administered on Resident 3's MAR but did not actually administer the medication. LVN 7 confirmed the Promacta medication was not administered to Resident 3 as ordered by the physician. LVN 7 stated he did not notify Resident 3's physician or the next shift that Resident 3's Promacta was not administered.
Review of Resident 3's Progress Notes dated 10/21/23 at 2108 hours, showed the DON was notified by Resident 3's family at 0800 hours of 10/21/23, regarding Resident 3 not receiving his Promacta dose that day. The DON reached out to LVN 7; however, LVN 7 called the DON back at 1821 hours, that evening and confirmed the Promacta medication had not been given that morning to Resident 3. The MD was notified and a onetime dose of Promacta was ordered to be administered to Resident 3 that night.
On 11/13/23 at 1500 hours, an interview was conducted with the DON. The DON stated medications should be administered within one hour of the prescribed time. The DON confirmed the physician should have been notified if a medication was not administered to a resident.
Review of Resident 3's Progress Notes dated 10/21/23, showed Resident 3 was administered his dose of Promacta 50 mg at 2151 hours, approximately 15 hours after Promacta 50 mg was prescribed to be given.
Cross reference to F842.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medications brought by the family was accurately...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medications brought by the family was accurately and safely accounted for one of three sampled resident (Resident 3). This failure had resulted in a missing dose of Resident 3's medication.
Findings:
Medical record review for Resident 3 was initiated on 11/7/23. Resident 3 was admitted to the facility on [DATE].
Review of Resident 3's Order Summary Report showed a physician's order dated 10/18/23, to administer Promacta 50 mg (Eltrombopag Olamine) one tablet by mouth in the morning for thrombocytopenia/anemia with a start date of 10/19/23.
On 11/6/23 at 1537 hours, an interview was conducted with Resident 3's family member (Family Member 1). Family Member 1 stated she had personally delivered a 30-day supply of Promacta 50 mg to the facility and delivered it to the nursing station. However, Family Member 1 stated the facility had notified her one tablet was missing from Resident 3's supply.
On 11/13/23 at 1535 hours, an interviewand concurrent medical record review was conducted with LVN 2. Review of Resident 3's Progress Notes dated 10/17/23, showed a new order for Promacta 50 mg tablet was received. The document further showed Resident 3's family member was to pick up the medication from the hematologist's office and deliver the supply to the facility. LVN 2 verified the finding and added the administration of Promacta 50 mg was started on 10/19/23.
On 11/8/23 at 1611 hours, an interview was conducted with the DON. The DON verified the facility first counted the number of tablets inside Resident 3's 30-day supply of Promacta 50 mg bottle (a total of 30 tablets) on 10/21/23, instead of when it was delivered. The DON stated the facility counted 27 tablets in the bottle; however, Resident 3 only received two doses of Promacta 50 mg so far. The DON stated the Promacta 50 mg bottle was missing one tablet. The DON stated the facility could not confirm if there were any missing tablets when the bottle was delivered because the facility did not count the medication when it was first brought in by Resident 3's family.
On 11/13/23 at 1626 hours, a follow-up interview was conducted with the DON. The DON stated the facility failed to follow the proper procedure when receiving the medications brought in by the family.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to maintain the accurate medical record for one of three sampl...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to maintain the accurate medical record for one of three sampled residents (Resident 3) when LVN 7 inaccurately documented the administration of Resident 3's Promacta medication. This failure had the potential to cause a delay on Resident 3 receiving his medication.
Findings:
Medical record review for Resident 3 was initiated on 11/7/23. Resident 3 was admitted to the facility on [DATE].
Review of Resident 3's Order Summary Report showed a physician's order dated 10/18/23, to administer Promacta 50 mg (Eltrombopag Olamine) one tablet by mouth in the morning for thrombocytopenia/anemia with a start date of 10/19/23.
Resident 3's MAR for October 2023, showed Promacta 50 mg was scheduled to be given at time 0600 hours daily. Further review of the MAR showed on 10/21/23, Resident 3 was administered his Promacta by LVN 7.
On 11/9/23 at 1525 hours, a telephone interview was conducted with LVN 7. LVN 7 verified he took care of Resident 3 on 10/21/23. LVN 7 stated he could not locate Resident 3's Promacta medication on the morning of 10/21/23. LVN 7 added he had already signed the medication off as administered on Resident 3's MAR but did not actually administer the medication. LVN 7 confirmed the Promacta medication was not administered to Resident 3 as ordered by the physician.
Cross reference to F684.
Aug 2023
1 deficiency
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Report Alleged Abuse
(Tag F0609)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report the facility's investigative findings to the State Agency, specific to an allegation of resident physical abuse, within five working days from being informed of the allegation for one of five sampled residents (Resident 1).
* The facility was informed of an allegation of Resident 1's physical abuse on 8/8/23 at approximately 1330 hours, and conducted an investigation specific to Resident 1's allegation of physical abuse; however, the facility failed to report the investigative findings to the State agency within five working days of the allegation. This failurehad the potential to inhibit the State agency's ability to investigate and determine whether the resident's physical abuse occurred in the facility.
Findings:
Review of the facility's P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 4/2021 showed the facility will investigate any allegations (of abuse) within timeframes required by federal requirements.
Medical record review for Resident 1 was initiated on 8/8/23. Resident 1 was admitted to the facility on [DATE].
Review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form dated 8/8/23, showed the facility was informed on 8/8/23 of an allegation of physical abuse involving Resident 1, in which Resident 1 allegedly sustained bruising to his body.
On 8/16/23 at 1339 hours, an interview was conducted with the Administrator. The Administrator stated the facility had conducted an investigation specific to the physical abuse allegation involving Resident 1. The Administrator was asked if he had submitted the facility's investigative findings to the State agency within five working days. The Administrator stated no, the facility had not submitted the investigative findings to the State agency.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to document the information relevant to a resident discharge f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to document the information relevant to a resident discharge forone of two sampled residents (Resident 1).
* Resident 1's scheduled eye appointment was not documented on Resident 1's discharge documents.
* Resident 1's hearing appointment was not scheduled.
These failures posed the risk of Resident 1 not receiving appropriate care.
Findings:
Closed medical record review for Resident 1 was initiated on 7/21/23. Resident 1 was admitted to the facility on [DATE], and discharged to another facility on 4/7/23.
Review of Resident 1's History & Physical Examination dated 1/10/23, showed Resident 1 was admitted to the facility with diagnoses including diabetes and hearing loss.
a. Review of Resident 1's Order Summary Report for April 2023 showed Resident 1 had an eye specialist appointment scheduled for 8/2/23.
Review of Resident 1's discharge documentation and Discharge Summary failed to show Resident 1's eye appointment information was provided to Resident 1 upon her discharge.
b. Review of Resident 1's Order Summary Report for April 2023 showed Resident 1 had an order dated 2/22/23, to schedule an appointment with a hearing specialist.
Review of Resident 1's medical record failed to show Resident 1's hearing specialist appointment was scheduled.
On 7/25/23, at 1550 hours, the above findings were verified with the DON.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was free from the sexual abuse.
* LVN 1 was found in bed half naked with pants on and cuddling with Resident 1 during the night shift. Resident 1 had fluctuating capacity to understand and make medical decisions. This failure had the potential to negatively impact Resident 1's well-being.
Findings:
Review of the facility's P&P titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021 showed the following:
- Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.
- Protect resident from abuse, neglect, exploitation, or misappropriation of property by anyone including but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and/or any other individuals.
- Conduct employee background checks and not knowingly employ or otherwise engage any individual who has:
a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;
b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or
c. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.
Review of the facility's P&P titled Background Screening Investigations revised March 2019 showed the facility conducts the employment background screening checks, reference checks, and criminal conviction investigation checks on all applicants for positions with direct access to residents. The Director of Personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment.
Review of the facility's P&P titled Compliance and Ethics Program - Code of Conduct and Statement Purpose dated December 2020 showed the purpose of the Compliance and Ethics Program is to prevent and detect criminal, civil and administrative violation under the Social Security Act, and to ensure quality of care for our residents.
Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 7/10/23, showed a licensed nurse was found in bed with a resident, cuddling with resident half naked with pants on.
Closed medical record review for Resident 1 was initiated on 7/11/23. Resident 1 was admitted to the facility on [DATE], and discharged home on 7/11/23.
Review of Resident 1's H&P examination dated 5/15/23, showed Resident 1 had fluctuating capacity to understand and make medical decisions. The H&P examinationalso showed Resident 1 had impaired mobility, muscle weakness, seizures (sudden, uncontrolled burst of electrical activity in the brain), Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), hypertension (high blood pressure), and diabetes mellitus (a disease in which the body does not control the amount of glucose (type of sugar) in the blood and the kidney make a large amount of urine).
Review of Resident 1's physician's progress notes dated 5/12, 5/22, 5/28, 6/8, and 6/27/23, showed Resident 1 had fluctuating capacity to understand and make medical decisions.
Review of Resident 1's MDS dated [DATE], showed Resident 1 had moderately impaired cognition.
Review of Resident 1's Nurse's Note dated 7/10/23, showed a report was made to the DON from RN 1 that a resident was cuddling in bed with a female staff half naked with pant on while in bed. The staff was able to dress the employee, clocked her out, and a CNA took her home to her apartment. Resident 1 was assessed for any distress and was not affected by the incident. Resident 1's family member was notified and reassured LVN 1 had no longer employed with the facility.
On 7/12/23 at 1031 hours, a telephone interview was conducted with Resident 1. Resident 1 was asked if he recalled the incident that occurred on Monday, 7/10/12, early morning around 0030 hours. Resident 1 stated he was in bed. Then there was a young lady that crawled in bed with him. Resident 1 stated the lady started talking. Resident 1 stated he was trying to figure out what was going on. Resident 1 stated he was laying on his right side and the lady was laying chest to chest on him. Resident 1 stated it did not occur for him to ask the lady to stop because he was surprised and enjoying. Resident 1 was asked if he recognized the lady or had any relationship with the lady. Resident 1 stated, No. I don't know that person. I don't even know how she looked like. I don't have any relationship with her.
On 7/11/23 at 1455 hours, the DON and Administrator discussed some of their preliminary investigative findings. The DON stated Resident 1 was assessed, Resident 1's family member was notified, the police came to interview Resident 1, the alleged allegation was reported to the Ombudsman and CDPH, and LVN 1 was immediately terminated. The DON stated Resident 1 was discharged in the morning and Resident 1's discharge was planned.
On 7/12/23 at 0855 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 1 was alert and oriented but not 100% there.
On 7/12/23 at 0916 hours, an interview was conducted with LVN 3. LVN 3 stated she was familiar with Resident 1. LVN 3 stated Resident 1 was alert, oriented and could answer simple questions.
On 7/12/23 at 0950 hours, an interview was conducted with RN 2. RN 2 stated she completed the discharge for Resident 1. RN 2 stated Resident 1 was pleasant, confused but able to respond and follow commands and instructions.
On 7/12/23 at 1111 hours, a telephone interview was conducted with RN 1. RN 1 stated a CNA was looking for LVN 1 because LVN 1 could not be found, and a resident was asking for medications. RN 1 stated another licensed nurse found a lady in bed with Resident 1. The licensed nurse reported it to RN 1. RN 1 stated she went to Resident 1's room with the licensed nurse. RN 1 stated she recognized it was LVN 1 because of her hair. RN 1 saw thenursing scrubs clothing on the floor and LVN 1 in bed with Resident 1 with her bra on only. RN 1 stated she prompted LVN 1 to get up, put her clothes on, and escorted her out of Resident 1's room to the Activities room. RN 1 stated she called the DON and was directed to tell LVN 1 to clock out and go home. RN 1 stated she followed the DON's instructions. RN 1 stated she went back to Resident 1 and asked Resident 1 what happened. Resident 1 told RN 1 he did not know what happened and it was the first time he saw LVN 1.
On 7/12/23 at 1525 hours, a telephone interview was conducted with LVN 1. LVN 1 was asked if she could give information about what happened on Monday, 7/10/23, early morning. LVN 1 she was prompted to go to Resident 1's room because she recognized the name of Resident 1. LVN 1 stated she knew Resident 1 when she was [AGE] years old, but they had to go in different ways. LVN 1 stated she could not be together with Resident 1 a long time ago and met him again that day. LVN 1 stated she was lying in bed with Resident 1. LVN 1 confirmed she took her top scrubs off and that was it. LVN 1 stated Resident 1 did not recognized her.
On 7/13/23 at 0700 hours, a telephone interview was conducted with CNA 4. CNA 4 stated around 0030 hours on Monday, 7/10/23, she heard the other nurses looking for LVN 1. CNA 4 stated she saw LVN 1 going into Resident 1's room but did not notice LVN 1 leaving the room. CNA 4 stated she heard giggling in Resident 1's room but did not think any of it since the television was on. CNA 4 stated she went into Resident 1's room and saw scrubs on the floor. CNA 4 stated she saw a female person naked from the top part of her body and Resident 1 without his gown on, both laying on Resident 1's bed together. CNA 4 stated she reported what she saw to the nearest licensed nurse and went back to Resident 1's room to get LVN 1 out of Resident 1's bed. CNA 4 was asked to describe Resident 1's reaction to the incident. CNA 4 stated Resident 1 looked fine as if nothing happened. CNA 4 further stated, I don't think he (Resident 1) was fully aware of what was going on.
Review of LVN 1's personnel employee file showed LVN 1 was hired on 1/17/23. LVN 1's personnel employee file failed to show the background check was completed prior to LVN 1 hire date. The New Hire Reference Check dated 1/11/23, was incomplete. The New Hire Reference Check document did not show documented evidence of the attempted calls for LVN 1's references.
Review of LVN 1's Separation of Employment form dated 7/10/23, showed termination for gross misconduct.
On 7/12/23 at 1440 hours, an interview and a concurrent facility document review was conducted with the DON. The DON verified there were no background check documents filed in LVN 1's personnel employee file folder. The DON provided a document titled BeenVerified (a background check company that provides consumer initiated criminal background and people search services through its website) (undated) to show LVN 1's background check with a different name compared to LVN 1's name in her LVN license. The DON also verified LVN 1's reference checklist document was incomplete.
On 7/13/23 at 1113 hours, an interview and concurrent facility document review was conducted with the Corporate DSD/IP/QA Specialist. The Corporate DSD/IP/QA Specialist stated the background checks for new hires should be completed after the applicant had accepted an offer letter before the new hire started their first day of orientation. The Corporate DSD/IP/QA Specialist verified LVN 1's background check documents given by the DON wereundated and agreed there was no date to determine when the background check was ordered or completed. The Corporate DSD/IP/QA Specialist verified with the comparison LVN 1's personnel employee file against another this year's newly hired LVN's personnel employee file showed the background check had an ordered date to show it was completed before the first day of the hire date and was different from LVN 1's background check documents. The Corporate DSD/IP/QA Specialist also confirmed LVN 1's reference checklist document was incomplete.
Jun 2023
26 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and medical record review, the facility failed to ensure the call light for one of 27 final sampled residents (Residents 81) was answered promptly. In addition, the fa...
Read full inspector narrative →
Based on observation, interview, and medical record review, the facility failed to ensure the call light for one of 27 final sampled residents (Residents 81) was answered promptly. In addition, the facility failed to ensure Resident 81's call light was within the resident's reach. These failures had the potential for the residents to not get their needs met timely.
Findings:
On 6/8/23 at 1017 hours, Resident 81 was observed awake in bed. Resident 81's right leg was seen dangling on the right side of the bed and the resident attempted to lean forward but could not. Resident 81 stated, have you seen my shoes? I want to go outside to get some air. Resident 81's call light cord was noted tangled around the left side rail and the call light button was hanging and almost touching the floor. Resident 81 tried pulling the call light cord but could not get the call light button.
On 6/8/22 at 1022 hours, a staff was called to assist Resident 81. Resident 81 was then observed pressing up and down the buttons on the bed remote control. Resident 81 used the bed's remote control to raise the head of bed up. Resident 81 asked for the wheelchair so she could wheel herself out.
On 6/8/22 at 1027 hours, a call light button in bed A was pressed for Resident 81.
On 6/8/23 at 1028 hours, RNA 2 was observed assisting another resident in the room. RNA 2 was observed turning the call light off without asking Resident 81 if Resident 81 needed assistance. When RNA 2 was asked about Resident 81's call light, RNA 2 acknowledged she turned off the call light without asking Resident 81 if the resident needed assistance. RNA 2 was observed assisting the other resident to the bathroom.
On 6/8/23 at 1030 hours, CNA 8 came into the room to assist Resident 81. CNA 8 was observed repositioning Resident 81. CNA 8 verified Resident 81's call light was not within the resident's reach. CNA 8 was noted untangling the call light cord from the side rail.
On 6/12/23 at 0921 hours, an interview was conducted with RNA 2. RNA 2 acknowledged she turned off the call light on 6/8/23, without asking Resident 81 if the resident needed any assistance. RNA 2 stated she turned off the call light on bed A because she was already assisting the resident in bed A.
On 6/13/23 at 0926 hours, an interview was conducted with the DON. The DON stated the call lights should be placed within the resident's reach and for the staff to answer the call light promptly. The DON stated when a call light was turned on, any staff should answer and even if the call light was for another bed, the staff should ask the other residents in the room to make sure they recevied assistance when needed.
Cross reference to F689, example #2.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to notify Responsible Party 1 of a chang...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to notify Responsible Party 1 of a change in condition for one nonsampled resident (Resident 24).
* The facility failed to notify Responsible Party 1 when Resident 24 had new medication orders, lab orders, and new appointment.
This failure had the potential to negatively impact the resident's psychosocial and physical wellbeing and prevent the resident's responsible party from being fully aware of the resident's treatments, understand the course of actions, and not make appropriate decisions in the care and treatment of Resident 24.
Findings:
Review of the facility's P&P titled Change in a Resident's Condition or Status revised date 2/2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/ mental condition and/ or status (such as changes in level of care, billing/ payments, resident rights, etc.)
A significant change of condition is a major decline or improvement in the resident's status that:
a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting);
b. impacts more than one area of the resident's health status;
c. requires interdisciplinary review and/or revision of care plan; and
d. ultimately based on the judgment of the clinical staff and the guidelines outlines in the Resident Assessment Instrument.
Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/ mental condition or status. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/ her medical care or nursing treatments. The nurse will record in the resident's medical record information relative to changes in the resident's medical/ mental condition or status.
Medical record review for Resident 24 was initiated on 6/5/23. Resident 24 was admitted to the facility on [DATE].
Review of Resident 24's face sheet showed Responsible Party 1 listed as the emergency contact 1, responsible party, and DPOA-Financial (Durable Power of Attorney, authorizing an agent to manage financial affairs).
Review of Resident 24's MDS dated [DATE], showed Resident 24 had a severe cognitive impairment.
On 6/9/23 at 1630 hours, a telephone interview was conducted with Responsible Party 1 regarding a phone complaint filed to the CDPH L&C by Responsible Party 1. Responsible Party 1 stated Resident 24 had been in the facility for two years, and he was not regularly notified when Resident 24 had any change of condition. Responsible Party 1 stated Resident 24 recently went for a medical appointment, and he was not notified regarding new medication, new laboratory result, new appointment or about a serious medical condition. Responsible Party 1 stated when he called the facility to inquire of Resident 24's condition, he would not get any call back from the facility.
Review of Resident 24's medical record did not show Responsible Party 1 was notified when Resident 24 had new medication orders, laboratory results, new medical appointments. For example:
a. Review of Resident 24's Progress Notes showed a nurse's note dated 5/14/22 at 1611 hours, showing the facility left a message to Responsible Party 1 for the BUN (Blood Urea Nitrogen, test to measure the amount of urea nitrogen found in the blood, normal level 7-20 mg/dl) result of 39 mg/dl, and with a new order of IV fluids.
Review of the medical record did not show Responsible Party 1 was called to follow-up.
b. Review of Resident 24's Progress Notes showed a nurse's note dated 6/22/22 at 0551 hours, showed the physician was at the facility and ordered Bactrim (antibiotic) for an infection.
Review of the medical record did not show Responsible Party 1 was notified regarding the new medication order.
c. Review of Resident 24's Progress Notes showed a nurse's note dated 3/8/23 at 0811 hours, showed a new order for laboratory for CBC (Complete Blood Count, a test that measures the red blood cells and white blood cells) for long-term anticoagulation use as per the pharmacy medication regimen review.
Review of the medical record did not show Responsible Party 1 was notified regarding the new medication order.
d. Review of Resident 24's Progress Notes showed a nurse's note dated 5/31/23 at 0926 hours, showed a new order for laboratory evaluation for CBC, and PT/PTT INR (Prothrombin Time Test and International Normalized Ratio. The PT/ PTT test measures how long it takes for a clot to form in a blood sample. INR is a type of calculation based on the prothrombin test result) on 6/1/23, as per the pharmacy recommendation. The note showed, RP (responsible party) made aware.
Review of Resident 24's Progress Notes showed a nurse's note dated 6/1/23 at 1556 hours, showed the laboratory results for CBC and PT/PTT INR were relayed to the NP (nurse practitioner). The note showed the NP had new orders for gastrointestinal consult, stool occult-blood (a laboratory test to check stool samples for hidden or occult blood), iron panel, B12 and folate level, and new order for Protonix medication (used to treat high levels of stomach acid). The note showed, orders noted and carried out, and resident was made aware.
Review of the medical record did not show Responsible Party 1 was notified regarding the new for gastrointestinal consult, stool occult-blood, iron panel, B12 and folate level, and new order for Protonix medication.
e. Review of Resident 24's Progress Notes showed a nurse practitioner note dated 6/6/23 at 1300 hours, showed Resident 24 returned from a medical appointment with a new order for ferrous sulfate (iron supplement), and to return on or around 12/2/23, and a laboratory evaluation on 12/6/23.
Review of the After Visit Summary report dated 6/6/23, showed a blood specimen was collected on 6/6/23, and the results were: hemoglobin 11.1 (a protein in red blood cells that carried oxygen, normal level is 14 to 18 g/dl in males) and hematocrit 37.3 (percentage of red blood cells in the blood, normal level is 41 to 50%). Review of the report also showed a handwritten note for his anemia, please start Ferrous Sulfate every other day.
Further review of the report showed the following blood tests were ordered on or around 12/6/23:
- lipid profile (a blood test to monitor cholesterol levels);
- hemoglobin a1c (a blood test to measure the average blood sugar levels over the past three months)
- urinalysis (a urine test)
- TSH blood (Thyroid Stimulating Hormone test, a blood test to measure this hormone)
- CBC
- prostate specific antigen (a blood test to measure the level of protein produced in the prostate gland)
- simplified metabolic panel (a basic metabolic panel, a test to measures the eight substances in the blood such as calcium, carbon dioxide, chloride, creatinine, potassium, sodium, and BUN); and
- liver function panel (blood test to measure the different enzymes, proteins, and other substances made by the liver)
The report also showed another appointment order for Resident 24 to return on or around 12/3/23.
Review of the medical record did not show Responsible Party 1 was notified regarding the laboratory result, new medication order for ferrous sulfate medication, new laboratory evaluation orders, and new appointment order.
On 6/12/23 at 1608 hours, an interview and concurrent medical record review for Resident 24 was conducted with the DON. The DON verified the above findings. The DON stated when a resident had a change of condition, the LVN or RN would notify the physician, and then notify the resident's responsible party. When asked about a change of condition, the DON stated a change of condition would be anything different from the normal such as fever, cough, nausea, vomiting, a new skin condition, or a change of level consciousness. The DON also stated the licensed nurses notified the responsible party when the facility notified the physician, and there were new orders for laboratory, medications, treatment, or appointment. When asked if there was a timeframe of when to notify the responsible party, the DON stated the notification of a change of condition should be at least within 24 hours, but the licensed nurses did not have to wait for the next day. The DON stated the licensed nurses notified the responsible party right away. The DON stated when the licensed nurses called the responsible party and there was no answer, the licensed had to call back to follow up, or had to endorse to the next shift to follow-up. The DON stated the notification of the change of condition would be documented in the progress notes or in the eInteract SBAR (Situation, Background, Assessment, Recommendation is a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations.) in the resident's electronic health record. When asked about Resident 24, the DON verified Responsible Party 1 was the responsible party for Resident 24. The DON verified there was no documentation showing Responsible Party 1 was notified when Resident 24 had a change of condition, new medication orders, new laboratory results, or new appointments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the restraint ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the restraint free periods and least restrictive measures for one of 27 final sampled residents (Resident 72) when Resident 72's bed was placed against the wall without medical necessity. This failure posed the risk of compromising Resident 72's independence and had the potential for increased risk of physical harm to the resident.
Findings:
Review of the facility's P&P titled Use of Restraints revised 4/2017 showed the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to: treat the medical symptom, protect the resident's safety, and help the resident attain the highest level of his/her physical or psychological well-being.
During an initial tour of the facility on 6/5/23 at 1500 hours, Resident 72 was observed in bed with the left side of the bed against the wall. The side rails were observed elevated on both sides of the bed, and a floor mat was observed on the right side of the bed. A bed alarm was observed hanging from the right side rail.
Medical record review for Resident 72 was initiated on 6/7/2023. Resident 72 was admitted to the facility on [DATE].
Review of Resident 72's Nurse Practitioner Notes dated 12/2, 12/7, 12/9, 12/12, 12/15, 12/19, 12/23, 12/27, and 12/30/22, showed no documented evidence of Resident 72's condition requiring the resident's bed to be against the wall and no changes to the current plan of care during the above dates.
Review of Resident 72's MDS dated [DATE], showed Resident 72 had severe cognitive impairment.
Review of the Order Summary Report dated 6/8/23, showed the following orders:
- a physician's order dated 11/30/22, to have the top half side rails up x 2 (times two) as an aid to bed mobility/turning and repositioning.
- a physician's order dated 12/19/22, to have the bed against the wall for safety per family request.
- a physician' order dated 4/17/23, for a pressure sensitive alarm in bed and restraint free alarm in wheelchair for safety awareness.
On 6/12/23 at 0850 hours, Resident 72 was observed in bed with the the left side of the bed against the wall. The side rails were observed elevated on both sides of the bed, a bed alarm was hanging from the right side rail, and a floor mat was observed on the right side of the bed.
On 6/12/23 at 1041 hours, an interview with CNA 4 was conducted. CNA 4 was asked what the purpose was of having the left side of the bed against the wall. CNA 4 stated it was placed against the wall for safety per family request. CNA 4 stated the bed alarm was used in case she tried to get up out of bed.
On 6/12/23 at 1050 hours, an interview was conducted with MDS Coordinator 1. MDS Coordinator 1 stated Resident 72 was able to get up by herself and able to move around. MDS Coordinator 1 stated the bed was against the wall per family request for safety and to prevent her from going out from the other side of the bed. MDS Coordinator 1 acknowledged if the bed was not against the wall, Resident 72 would be able to get out of bed from the other side.
On 6/12/23 at 1305 hours, an interview was conducted with the DON. The DON stated the bed against the wall was used for Resident 72's fall safety risk. The DON verified Resident 72 would be able to get out of bed from the other side if it was not against the wall. The DON verified there was no documentation regarding least restrictive measures prior to placing Resident 72's bed against the wall.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 6/5/23 at 1500 hours, and 6/12/23 at 0845 hours, Resident 72 was observed in bed with the left side of the bed against the...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 6/5/23 at 1500 hours, and 6/12/23 at 0845 hours, Resident 72 was observed in bed with the left side of the bed against the wall. Side rails were observed elevated on both sides of the bed.
Medical record review for Resident 72 was initiated on 6/7/23. Resident 72 was admitted to the facility on [DATE].
Review of Resident 72's MDS dated [DATE], showed Resident 72 had severe cognitive impairment and required extensive assistance from two staff for bed mobility.
Review of the Order Summary Report as of 6/8/23, showed a physician's order dated 11/30/22, to have both top half side rails up as an aid to bed mobility/turning and repositioning.
However, further review of Resident 72's medical record failed to show documented evidence a care plan problem was developed to address Resident 72's need for side rails.
On 6/12/23 at 0901 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above finding. The DON verified there was no care plan developed to address the use of side rails for Resident 72.
Cross reference to F700.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for four of 27 final sampled residents (Residents 72, 88, 96, and 727) and one of 21 nonsampled residents (Resident 114).
* The facility failed to develop an individualized a care plan problem to address Resident 114's use of ipratropium- albuterol medication (a breathing treatment that works by relaxing and opening air passage to the lungs to make breathing easier) and implementation of enhanced standard precaution related to infection in the urine.
* The facility failed to develop an individualized care plan problem to address Resident 727's use of bilateral foam boots (heel boot that protects and support heel and ankle for pressure build up and friction)
* The facility failed to develop a comprehensive person centered care plan to address the use of side rails for Resident 72.
* The facility failed to develop a comprehensive person centered care plan to address the respiratory care needs of Resident 88.
* The facility failed to develop a comprehensive person centered care plan to address Resident 96's smoking.
These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.
Findings:
Review of the facility's P&P titled Care Plans Comprehensive Person-Centered revised March 2022 showed the comprehensive, person-centered care plan should include measurable objectives and time frames; describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, psychosocial well-being that the resident desires or that is possible, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights (including the right to refuse treatments); and any specialized services to be provided as a result of PASSRR recommendations.
1. Medical record review for Resident 114 was initiated on 6/7/23. Resident 114 was readmitted to the facility on [DATE].
a. Review of Resident 114's laboratory result for urine culture dated 6/1/23, showed an abnormal culture results of greater than 100,000 colonies/ml of vancomycin resistant enterococcus faecium (bacteria that normally live in the intestines and would not cause any harm, but if they get into certain places in the body, such as the urinary tract, bloodstream, or a wound, they can could an infection).
Review Resident 114's Order Summary Report for June 2023 showed a physician's order dated 6/1/23, to place Resident 114 on enhanced standard precaution related to infections. Handwashing/hand sanitizing, gown, and gloves were required.
However, on 6/7/23 at 0856 hours, Resident 114's room was observed without any signage for enhanced standard precautions and did not have a cart with PPEs needed for enhanced standard precautions outside the room for staff to use.
Review of Resident 114's plan of care failed to show documented evidence a care plan problem was developed to address Resident 114's infection and the implementation of enhanced standard precautions.
b. During a medication pass observation on 6/7/23 at 0850 hours, LVN 1 was observed administering a breathing treatment to Resident 114. Resident 114's nebulizer tubing was undated.
Review Resident 114's Order Summary Report for June 2023 showed a physician's order dated 5/23/23, to administer ipratropium-albuterol 0.5-2.5 mg/3 ml 3 ml inhale orally via nebulizer every four hours for SOB/wheezing administered routinely every four hours daily.
Review of Resident 114's plan of care showed a care plan problem addressing respiratory care revised on 6/5/23. However, the care plan problem did not address the respiratory treatment of ipratropium- albuterol.
On 6/8/23 at 0944 hours, an interview and concurrent medical record review was conducted with MDS Coordinator 2. MDS Coordinator 2 verified Resident 114's care plan did not address the implementation of enhanced standard precautions and the use of breathing treatment.
Cross reference to F880, example #4.b.
2. On 6/6/23 at 1003 hours, Resident 727 was observed in bed wearing a foam boot on the left heel and the other foam boot was on top of the bed.
On 6/7/23 at 0904 hours, Resident 727 was observed in bed wearing bilateral foam boots.
Medical record review for Resident 727 was initiated on 6/6/23. Resident 727 was admitted to the facility on [DATE].
Review of Resident 727's H&P examination dated 3/18/23, showed Resident 727 had the capacity to understand and make decisions.
Review of Resident 727's Order Summary Report for June 2023 showed a physician's order to apply bilateral foam boots while Resident 727 was in bed, to remove and check for skin breakdown every shift.
Review of Resident 727's plan of care showed a care plan problem addressing altered skin integrity revised on 6/8/23. However, the care plan did not address the use of bilateral foam boots to prevent altered skin integrity.
On 6/8/23 at 0908 hours, an interview and concurrent medical record review was conducted with Treatment Nurse 1. Treatment Nurse 1 stated Resident 727 did not currently have wounds but used the bilateral foam boots for skin prevention. Treatment Nurse 1 verified the above findings and stated Resident 727's care plan should address the use of bilateral foam boots.
4. Medical record review for Resident 88 was initiated on 6/5/23. Resident 88 was admitted to the facility on [DATE].
Review of Resident 88's Order Summary for June 2023 showed a physician's order dated 3/23/23, to administer oxygen at 2 liters per minute via nasal cannula as needed for oxygen saturation level less than 92%. Another order dated 5/3/23, to administer budesonide inhalation suspension (a breathing treatment that works by relaxing and opening air passage to the lungs to make breathing easier) 0.5 mg/2 ml inhale orally via nebulizer two times a day.
However, review of Resident 88's plan of care failed to show documented evidence a care plan problem was developed to address Resident 88's use of oxygen and nebulizer treatment.
On 6/8/23 at 1016 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 88's plan of care did not address Resident 88's respiratory care needs.
5. Medical record review for Resident 96 was initiated on 6/5/23. Resident 96 was admitted to the facility on [DATE].
On 6/5/23 at 1131 hours, an interview was conducted with Resident 96. Resident 96 stated he smoke cigar once in a while and the nurse kept his smoking materials.
However, review of Resident 96's plan of care failed to show documented evidence a care plan problem was developed to address Resident 96's smoking.
On 6/7/23 at 1141 hours, an interview and concurrent medical record review for Resident 96 was conducted with the DON. The DON was informed and verified the finding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed the comprehensive, person...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed the comprehensive, person-centered care plan should include measurable objectives and time frames.
Medical record review for Resident 18 was initiated on 6/6/23. Resident 18 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 18's H&P examination dated 8/4/22, showed a diagnosis of COPD and the resident had the capacity to understand and make decisions.
Review of Resident 18's Order Summary Report dated June 2023 showed a physician's order dated 5/29/23, for oxygen administration at two liters per minute via nasal cannula continuously every shift for respiratory comfort.
Review of Resident 18's care plan initiated 6/18/22, and revised 6/5/23, showed to administer the oxygen as ordered and monitor the oxygen saturation levels as ordered. The care plan did not address any medical complications realated to the use of oxygen and COPD.
On 6/12/23 at 1458 hours, an interview with concurrent record review was conducted with the DON. The DON verified Resident 18's care plan was generic, not specific, and stated it should have been individualized.
4. Medical record review for Resident 92 was initiated on 6/5/23. Resident 92 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 92's H&P examination dated 5/9/23, showed Resident 92 had the capacity to understand and make decisions.
Review of Resident 92's Order Summary Report dated June 2023 showed a physician's order dated 6/7/23, to administer the oxygen at two to three liters per minute via nasal cannula as needed for shortness of breath and maintain the oxygen saturation levels greater than 90%.
Review of Resident 92's care plan initiated 5/17/23, showed to administer the oxygen as ordered and monitor the oxygen saturation levels as ordered. The care plan did not address any medical complications realated to the use of oxygen.
On 6/13/23 at 0853 hours, an interview with concurrent record review was conducted with the DON. The DON verified Resident 92's care plan was generic, not specific, and stated it should have been individualized. The DON stated the inaccurate care plan can cause miscommunication and confusion in providing the resident's care.
Based on medical record review, interview, and facility P&P review, the facility failed to ensure the comprehensive care plans for four of 27 final sampled residents (Residents 6, 18, 92, and 86) were revised.
* The facility failed to ensure Residents 6 and 86's care plans were revised to reflect the residents' severe weight losses. This failure posed the risk for Residents 6 and 86 to not receive the necessary care needed to maintain acceptable parameters of nutritional status.
* The facility failed to ensure Residents 18 and 92's care plans were person-centered and comprehensive to address the use of oxygen therapy and its related medical complications from COPD. This failure posed the risk for Residents 18 and 92 to not receive the necessary care needed.
Findings:
Review of the facility's P&P titled Care Plan, Comprehensive Person-Centered revised 3/22 showed in part, 8. The interdisciplinary team should receive and update the care plan: a. when there has been a significant change in the resident's condition; b. when the resident has been readmitted to the facility from a hospital stay.
1. Review of the Weights and Vitals Summary from 3/1/23 through 6/1/23, showed the following weights and comparisons for Resident 6:
* On 3/1/23, 157 lbs,
* On 4/1/23, 136.7 lbs, -20.3 lbs, a 12.9% severe weight loss in one month [comparison weight on 3/1/23, 157 lbs]; -18.3 lbs, a 11.8% severe weight loss in three months [comparison weight on 1/2/23 155 lbs],
* On 5/2/23, 136.4 lbs, -18.6 lbs, 12% severed weight loss in three months [comparison weight on 2/1/23 155 lbs],
* On 6/1/23, 128.4 lbs, -8.0 lbs, a 5.9% severe weight loss in one month [comparison weight on 5/2/23 136.4 lbs]; -28.6 lbs, a 18.2% severe weight loss in three months [comparison weight on 3/1/23 157 lbs].
Review of the resident centered care plan for Resident 6 titled At Risk for Altered Nutritional Status revised on 6/6/23, by the RN consultant, showed Resident 6 had weight loss, but it was beneficial; high BMI; now on oral gratification trying to stimulate oral intake; and to continue to assess weight loss.
On 6/8/23 at 1015 hours, an electronic medical record review for Resident 6 and concurrent interview was conducted with the DON. The DON stated the nursing staff was responsible to create a care plan or revise the existing care plan for any resident with a change of condition. The nutrition care plan for Resident 6 initiated on 4/26/23 and revised 6/6/23, was reviewed with the DON. The care plan for Resident 6 showed the resident had weight loss, but it was beneficial; high BMI (body mass index-a measurement comparing height and weight); now on oral gratification trying to stimulate oral intake; and to continue to assess weight loss. The DON stated the nutrition care plan was revised by the RN consultant. The DON was asked if a weight loss in the elderly was ever beneficial. The DON stated that depended on a resident's weight goal. The DON confirmed Resident 6's care plan did not reflect Resident 6's severe weight loss between 4/1-6/1/23, or have weight goal. The DON confirmed if a resident had a planned or beneficial weight loss, it should be coded as such in the MDS assessment. The DON further confirmed the physician should determine if weight loss was beneficial.
On 6/8/23 at 1025 hours, a telephone interview was conducted with the RN consultant. The RN consultant was asked how she determined the severe weight loss for Resident 6 was beneficial. She stated an IDT meeting was held and Resident 6's BMI of 31 was discussed. The RN consultant added Resident 6 had returned from the hospital and the IDT discussed to encourage oral intake for Resident 6. The RN consultant stated a resident who was transitioning off an enteral feeding was expected to lose weight. The RN consultant stated the IDT meeting was informal and she was not sure the meeting was documented. The RN consultant confirmed the physician and responsible party for Resident 6 were not contacted regarding the plan to transition Resident 6 off the enteral feeding. The RN consultant stated she submitted her recommendations regarding Resident 6 via email to the DON. The DON was unable to confirm documentation from the RN consultant that recommended Resident 6 be transitioned off the enteral feeding.
2. Review of the Weights and Vitals Summary from 3/1/23 through 6/1/23, showed the following weights and comparisons for Resident 86:
* On 3/1/23, 150 lbs,
* On 4/1/23, 132 lbs, -18 lbs, a 12% severe weight loss in one month [comparison weight on 3/1/23, 150 lbs]; -15 lbs, a 10% severe weight loss in three months [comparison weight on 1/2/23 147 lbs],
* On 5/2/23, 133.6 lbs, -14.4 lbs, 9.7% severe weight loss in three months [comparison weight on 2/1/23 148 lbs], -16.4 lbs,
* On 6/1/23, 128.4 lbs, -21.6 lbs, 14.4% severe weight loss in three months [comparison weight 3/1/23 150 lbs].
Review of the resident centered care plan titled Nutrition Care Plan initiated on 5/7/23, by LVN 12 for Resident 86 showed in part, Resident 86 was at risk for altered nutritional status, malnutrition and dehydration related to: impaired mobility, .DM (diabetes mellitus), hypothyroidism, dysphagia (difficulty swallowing), GT (gastrostomy tube), .The goal of Resident 86's care plan showed will have no signs or symptoms of dehydration. The intervention/task showed in part: RD assessment as indicated, weigh on admission, monthly and as indicated, and notify the MD, RD, family of significant weight changes.
Review of the resident centered care plan revised on 6/6/23 by the RN consultant titled Requires enteral regime for nutritional support for Resident 86 showed in part, on 6/6/23, weight was WNL (within normal limits). The care plan goal showed in part, to be able to have planned weight gain. The interventions/tasks showed in part, weight as indicated.
An electronic medical record review for Resident 86 and concurrent interview was conducted with the DON on 6/12/23 at 1010 hours. The nutritional care plan for Resident 86 was reviewed. The DON confirmed the nutritional care plan for Resident 86 was last revised on 5/7/23, and did not reflect Resident 86's severe weight loss between 1/2/23 and 6/1/23. The DON confirmed the care plan addressing the resident required enteral regime for nutritional support last revised on 6/6/23 did not reflect Resident 86's severe weight loss between 1/2/23 and 6/1/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide a safe environme...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for two of 27 final sampled residents (Residents 81 and 96) as evidenced by:
* The facility failed to ensure the smoking materials were securely stored. In addition, Resident 96 had been assessed with a need for a smoking apron and was not provided with a smoking apron during the smoking period. This posed the risk for serious injury to Resident 96.
* The facility failed to provide a floor mat as per the IDT and PT recommendations for Resident 81 following a fall on 3/18/23. In addition, the facility failed to complete the neurological assessments (neurological/neuro checks are brief, serial bedside exams performed by the nursing staff to evaluate for changes in the clinical status or neurological function) following Resident 81's fall on 9/27/22 and 3/18/23. These failures had the potential to cause injury to Resident 81 in case of another fall to occur, including the potential to delay the detection and response to the resident's neurological status changes post fall.
Findings:
1. Review of the facility's P&P titled Smoking Policy - Residents dated August 2022 showed the resident will be evaluated on admission for the ability to smoke safely with or without supervision (per the completed Safe Smoking Evaluation). The resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive), and as determined by the staff. Any smoking related privileges, restrictions, and concerns (for example, the need for close monitoring) shall be noted on the care plan. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking.
Medical record review for Resident 96 was initiated on 6/5/23. Resident 96 was admitted to the facility on [DATE].
On 6/5/23 at 1131 hours, an interview was conducted with Resident 96. Resident 96 stated he smoked cigar once in a while and the nurse kept his smoking materials.
On 6/6/23 at 0909 hours, Resident 96 was observed in the smoking patio area smoking his cigar, not wearing any protective device and with no staff supervision.
On 6/7/23 at 0913 hours, Resident 96 was observed in his wheelchair and assisted by the MDS nurse being wheeled outside to the smoking patio. Resident 96 was observed taking out his smoking materials from his storage pocket in his wheelchair. Resident 96 lit his cigar with a black color disposable lighter using his left hand.
Review of the Resident 96's Smoking Observation/assessment dated [DATE], showed Resident 96 had no cognitive impairment and had a dexterity problem. The safety section of the assessment showed Resident 96 could light his own cigarette, required a smoking apron, and may smoke without supervision. However, there was no information if the resident was safe to keep his smoking materials and no documentation if the resident was assessed as an independent smoker.
On 6/7/23 at 1010 hours, an observation and concurrent interview for Resident 96 was conducted with the MDS Coordinator. The MDS Coordinator verified she accompanied Resident 96 going to the smoking patio, placed the smoking apron unto the resident and stated she noted that Resident 96's smoking materials was with the resident when Resident 96 took them out from his pocket. The MDS Coordinator stated she asked Resident 96 if the resident kept the smoking materials with him and the MDS Coordinator was told by the resident, the nurse gave it to him. The MDS Coordinator stated they kept the smoking materials in the medication cart, locked by the medication nurse, and provided to the resident when they needed the materials. The MDS Coordinator asked LVN 5 who was the medication nurse if LVN 5 had provided the smoking materials to Resident 96. LVN 5 stated she did not provide the smoking materials to Resident 96. LVN 5 was asked if Resident 96's had any other remaining smoking materials being stored in the medication cart. LVN 5 inspected the medication cart and was not able to locate Resident 96's smoking materials.
On 06/07/23 at 1141 hours, an interview and concurrent facility's P&P review was conducted with the DON. The DON stated a smoking assessment for each smoking resident was conducted and the residents were informed about the facility's smoking P&P. The DON was informed of the above observation and findings about Resident 96's smoking materials being kept by the resident. The DON stated Resident 96 was noncompliant with regards on keeping his smoking materials. The DON stated Resident 96 should not keep his own smoking materials.
Cross reference to F656, example #5.
2. Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed based on previous evaluations and current data, the staff may identify intervention related to the resident's specific risks and causes in the attempt to reduce falls and minimize complications from falling.
Review of the facility's P&P titled Neurological Assessment revised 10/2010 showed the neurological assessments are indicated upon the physician's order, following an unwitnessed fall, following a fall or other accident/ injury involving a head trauma, or when indicated by the resident's condition.
Review of the facility's document titled Neurological Assessment Flowsheet (undated) showed the neurological assessments are to be completed every 15 minutes x 4, every 30 minutes x 2, every one-hour x 2, every 2 hours x 2, every four hours x 4, and every eight hours x 6, to complete the 72-hours neurocheck. The neurological assessment record include the following:
- Level of consciousness (alert, drowsy, stuporous, or comatose);
- Pupil response (PERL or pupil equal and reactive to light, brisk, sluggish, non-reactive, pinpoint, dilated, or fixed);
- Motor functions on hand grasp (equal, right greater than the left, left greater than the right, unable to follow commands or absent);
- Motor functions on extremities (moves all extremities, moves right arm, moves left arm, moves right leg, moves left leg, unable to follow commands, or absent);
- Pain response (appropriate pain response, inappropriate pain response, or no response to pain);
- Vital signs (blood pressure, temperature, pulse, and respirations); and
- Observations (such as seizures, headache, vomiting, or paralysis.
Medical record review for Resident 81 was initiated on 6/5/23. Resident 81 was admitted to the facility on [DATE].
Review of Resident 81's MDS dated [DATE], showed Resident 81 had a severe cognitive impairment.
Review of Resident 81's plan of care showed a care plan problem to address Resident 81's risk for fall related to an altered mental status, hearing impairment, and decreased muscular coordination.
Resident 81 was observed in bed with a floor mat on the left side of the bed in between Resident 81's bed and the roommate's bed on the following dates and times:
- On 6/6/23 at 0854 and 0909 hours.
- On 6/7/23 at 0926 and 1442 hours.
- On 6/8/23 at 1017 and 1030 hours.
- On 6/9/23 at 0846 hours.
On 6/8/23 at 1017 hours, Resident 81 was observed awake in bed. Resident 81's right leg was noted dangling on the right side of the bed, and the resident attempted to lean forward but could not. Resident 81 stated, have you seen my shoes? I want to go outside to get some air.
On 6/8/22 at 1022 hours, a staff was called to assist Resident 81. Resident 81 was then observed pressing up and down buttons on the bed remote control. Resident 81 was noted to be pressing the bed control button to raise the head of bed up. Resident 81 had asked for the wheelchair so she could wheel herself out.
On 6/8/23 at 1030 hours, CNA 8 came into the room to assist Resident 81. CNA 8 was observed repositioning Resident 81. CNA 8 verified there was a floor mat on the left side in between Resident 81's bed and the roommate's bed. When asked about the floor mat, CNA 8 stated the CNA did not know why there was only one floor mat, and maybe it was for Resident 81's roommate.
On 6/12/23 at 0845, 1024, 1033, 1436, 1437, 1540, and 1549 hours, Resident 81 was observed in bed, and there were no floor mats seen on either side of the resident's bed.
On 6/12/23 at 1024 hours, an observation for Resident 81 was conducted with LVN 1. Resident 81 was in bed and no floor mats were noted on either side of the bed. LVN 1 verified there were no floor mats provided for Resident 81.
a. Review of Resident 81's Progress Notes showed an eInteract SBAR Summary for Providers note dated 3/18/23 at 1945 hours, showed Resident 81 was found on the floor with her legs still on the bed and resident stated she was trying to go and visit her mother and did not notice the step was there. The documentation included the physician was notified and a neurocheck was ordered.
Review of Resident 81's Progress Notes showed an IDT - Fall note dated 3/20/23 at 1257 hours, showed Resident 81's current interventions related to the fall on 3/18/23, included neuro checks x 72 hours and apply bedside mat on the floor as precautions for fall.
Review of the Rehab - Status Post-Fall Screen dated 3/20/23, showed a recommendation for a fall mat on the right side of the bed. Per nursing, the resident tried to get out of the right side of the bed towards the door.
Review of the Neurological Assessment Flowsheet from 3/18 to 3/21/23, showed an incomplete entry for the assessment on the resident's hand grasp on 3/18/23 at 2230 hours. In addition, there was an incomplete entry for pupil responses on the 0700 to 1500 hours shift on 3/20 and 3/21/23.
b. Review of Resident 81's Progress Notes showed an eInteract SBAR Summary for Providers note dated 9/27/22 at 1350 hours, showed Resident 81 was seen sliding from the wheelchair to the floor in the hallway, and by the time the staff was able to reach the resident, Resident 81 was already sitting on the floor with her head resting on the wheelchair's seat.
Review of Resident 81's Progress Notes dated 9/27/22 at 1502 hours, showed the nurse's notified the nurse practitioner, and a neurocheck assessment was ordered.
Review of the Neurological Assessment Flowsheet dated 9/27 to 10/1/22, showed incomplete entries. For example:
- On 9/27/22 at 1400, 1415, 1420, and 1445 hours, there were no entries for Residents 81's pupil response right or left eye; and
- On 9/28/22 at 0900 hours, on 09/29/22 at 2300 to 0700 hours shift, and all shifts from 9/30 to 10/1/23, there was no documentation to show the neurological assessments were conducted.
On 6/12/23 at 1549 hours, an observation, interview, and concurrent medical record review for Residents 81 was conducted with the DON. Resident 81 was seen in bed, without any floor mat on the right side of the bed. The DON verified there was no floor mat provided for Resident 81. The DON verified a floor mat was recommended by the IDT and PT following Resident 81's fall on 3/18/23. When asked about the neurological assessments, the DON stated for any unwitnessed falls, the neurological assessments were to be completed for 72 hours and recorded on the Neurological Assessment Flowsheet form. The DON stated the frequency of assessments was indicated on the form. The DON verified Resident 81 had unwitnessed falls on 9/27/22 and 3/18/23. When asked about the neurological assessment for 72 hours for Resident 1's falls on 9/27/22 and 3/18/23, the DON verified the neurological assessments were incomplete.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the acceptable pa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the acceptable parameters of nutritional status were maintained for two of 26 final sampled residents (Residents 6 and 86) who were administered enteral (a form of liquid nutrition that is delivered into the digestive system via tube) feeding as evidenced by:
* The physician and responsible party were not notified of the severe weight losses for Residents 6 and 86.
* The interventions to mitigate the severe weight loss for Residents 6 and 86 were not implemented in a timely manner.
* The resident-centered plans of care for Residents 6 and 86 were not revised to address Resident 6 and 86's severe weight losses.
As a result of these failures, Resident 6 and 86's compromised nutritional status was not addressed timely, which could lead to further medical complications.
Findings:
A professional reference review of American Academy of Family Physicians Journal titled Unintentional Weight Loss in Older Adults dated 2014 showed unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments. (https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1)
A professional reference review of Dietetics in Healthcare Communities, a dietetic practice group of the American Dietetic Association titled Unintended Weight Loss in Older Adults: ADA Evidence Based Practice Guidelines dated 2011 showed most reference tables do not include elderly individuals in their subject pool, and thus these tables are not age adjusted. Standard height and weight tables and BMI tables are therefore not valid for use in older adults. (https://higherlogicdownload.s3.amazonaws.com/THEACADEMY/4556f4af-bcea-4fd9-8fc9-5647e0d15658/UploadedImages/DHCC/Documents_/UWL.pdf)
Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.
Review of the facility's P&P titled Weight Assessment and Intervention revised 9/2008 showed the multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. The Dietitian will respond within 24 hours of receipt of written notification. The Dietitian will review the unit weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met.
A professional reference review of Centers for Disease Control and Prevention, Healthy Weight, Nutrition and Physical Activity, Body Mass Index revised 6/3/22 showed, Body Mass Index (BMI) is a person's weight in kilograms (or pounds) divided by the square of height in meters (or feet). A high BMI can indicate high body fatness. BMI screens for weight categories that may lead to health problems, but it does not diagnose the body fatness or health of an individual. https://www.cdc.gov/healthyweight/assessing/bmi/index.html#:
Review of the facility's P&P titled Care Plan, Comprehensive Person-Centered revised 3/2022 showed the interdisciplinary team should receive and update the care plan when there has been a significant change in the resident's condition; and when the resident has been readmitted to the facility from a hospital stay.
1. Medical record review for Resident 6 was initiated on 6/7/23. Resident 6 was readmitted to the facility on [DATE], with diagnoses of gastrostomy (an opening into the stomach from the abdominal wall made surgically for the introduction of food) malfunction, contracture of muscle, hypothyroidism (abnormally low activity of the thyroid gland), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), fecal impaction (hardened stool that is stuck in the rectum or lower colon due to chronic constipation), aphasia (loss of ability to understand or express speech, caused by brain damage), and dysphagia (swallowing difficulties).
Review of Resident 6's H&P Examination dated 6/7/23, showed Resident 6 did not have the capacity to understand and make decisions; and the rehabilitation potential was poor.
Review of Resident 6's Quarterly MDS dated [DATE], showed Resident 6 had severe cognitive impairment, weighed 155 lbs, and had not experienced a 5% or more weight loss in the past month or 10% or more weight loss in the past six months. It also showed Resident 6 received 51% or more of total calories through a tube feeding and 501 cc/day or more of fluid intake by tube feeding.
Review of the facility's document titled IDT Weight Variance Assessment for Resident 6 completed by RD 1 on 4/3/23, signed and discussed with the IDT on 4/27/23, showed the following:
- Resident 6's weight was 136.7 lbs.
- GTF/flushes of Jevity (high protein fiber fortified formula) 1.2 at 50 cc/hr for 20 hours with water flushes of 30 cc/hr for 20 hours
- Weight loss of 18.3 lbs (11.8%)
- BMI 25 remained in healthy range
- Goal was weight stability
- The recommendation was to increase Jevity 1.2 to 65 cc/hr for 20 hours to provide 1300 cc 1560 kcals, 72 gm (grams) of protein, 1053 ml of free water, 130% RDI (recommended dietary intake with flushes of 1653 ml of total free water/day plus medication flushes
- Will monitor weight response and follow up PRN
However, review of the RD's recommendations dated 4/5 and 4/19/23, did not include the recommendation for Resident 6 from the RD assessment dated [DATE], to increase the GTF Jevity 1.2 to 65 cc/hr for 20 hours to provide 1300 cc, 1560 kcals.
Review Resident 6's Physician's Order Summary Report for June 2023 showed the following orders:
- Dated 4/19/23, to administer Jevity 1.2 HN at 50 cc/hr via feeding pump continuous for 20 hours/day for a total of 1000 cc/24 hours, 1200 kcal, on at 12 noon daily and off at 2000 hrs or until total volume completed; water flush at 30 cc/hr via feeding pump continuous for 20 hours/day for total volume of 600 cc water/day; and at least 30 cc of water before and after administration of medications.
- Dated 4/19/23, to perform weekly weights for four weeks
- Dated 4/20/23, to provide regular small portions diet pureed texture in divided plate for oral gratification and thin liquids consistency
Review of the Pulmonary Progress Note signed and dated by the Physician Assistant on 4/20/23, showed there were no new events reported, no new complaints, and to continue with the current care plan.
* However, Resident 6's severe weight loss was not addressed by the Physician Assistant.
Review of the RD recommendations for Resident 6 from 4/21 to 4/23/23, showed to increase Jevity 1.2 to 65 cc/hr for 20 hours with a total of 1300 cc, 1560 kcals, 72 gm of protein, and 1053 cc of free water.
Review of the New iMessage to Physician 1 dated 4/26/23, showed as per the RD's recommendation, please advise if okay to carry out for Resident 6 to increase Jevity 1.2 to 65 cc/hr for a total of 1300 cc, flushes of water 1053 cc. Physician 1 responded Ok.
* However, further review of the medical record showed no documented evidence the above physician's order was transcribed and carried out.
Review of Resident 6's Quarterly MDS dated [DATE], showed Resident 6 had severe cognitive impairment, weighed 136 lbs, and had experienced a 5% or more weight loss in the past month or 10% weight loss or more in the past six months. The MDS also showed Resident 6 was not on a physician-prescribed weight-loss regimen and received 51% or more of total calories through a tube feeding and 501 cc per day or more of fluid intake by tube feeding.
Review of the Resident 6's Nutritional Risk Review Quarterly initiated by RD 2 on 5/17/23, completed by RD 2 on 5/30/23, showed the following:
- Most recent weight on 5/2/23, showed 136.4 lbs
- Enteral/Parenteral Nutrition showed Jevity 1.2 at 50 cc/hr for 20 hours to provide 1000 ml, 1200 kcal/56 gm of protein, 807 ml of free water, 30 ml hourly water flush for a total of 1400 ml.
- Nutrition Goals/Monitoring and Evaluation was 136 lbs for two months, 156% BMI consistent with obesity, 18.6 lbs (-12%) weight loss in three months noted. Weight had been stable last two months, will monitor and adjust GTF as needed.
- The plan was to continue to monitor weight, laboratory results, skin, GTF tolerance and nutritional parameters.
Review of the Pulmonary Progress Note signed and dated by the Physician Assistant on 5/18/23, showed the resident complained of cough everyday.
* However, Resident 6's severe weight loss was not addressed by the Physician Assistant.
Review of the IDT Weight Variance Assessment for Resident 6 completed by RD 1 on 5/24/23, signed and discussed with the IDT on 6/5/23, showed the following:
- Resident 6 weighed 136.4 lbs
- GTF/flushes of Jevity 1.2 at 50 cc/hr for 20 hours, water flushes at 30 cc/hr for 20 hours
- Root Cause Analysis of -7.5% change [comparison weight 2/1/23 155 lbs, -12%, - 18.6 lbs] and 10% change [comparison weight 12/2/22 155 lbs, -12%, -18.6 lbs]
- BMI of 31.6 consistent with obesity.
- Likely factor for weight change may include multiple medical problems, fluid shifts, medications. Needs re-estimated based on actual weight of 62 kilogram: 1550-1850 kcals, 62-74 gm protein.
- The recommendation was to increase Jevity 1.2 to 60 cc/hr for 20 hours for a total of 1200 cc, 1440 kcal .
Review of the Resident 6's Weights and Vitals Summary from 3/1/23 through 6/1/23, showed the following weights and comparisons:
* On 3/1/23, 157 lbs,
* On 4/1/23, 136.7 lbs, -20.3 lbs, a 12.9% severe weight loss in one month [comparison weight on 3/1/23, 157 lbs]; -18.3 lbs, a 11.8% severe weight loss in three months [comparison weight on 1/2/23 155 lbs],
* On 5/2/23, 136.4 lbs, -18.6 lbs, 12% severed weight loss in three months [comparison weight on 2/1/23 155 lbs],
* On 6/1/23, 128.4 lbs, -8.0 lbs, a 5.9% severe weight loss in one month [comparison weight on 5/2/23 136.4 lbs]; -28.6 lbs, a 18.2% severe weight loss in three months [comparison weight on 3/1/23 157 lbs].
Review of Resident 6's plan of care showed a care plan problem addressing the risk for altered nutritional status revised by the RN Consultant on 6/6/23. The care plan problem showed Resident 6 had weight loss, but it was beneficial due to high BMI. The interventions showed the resident was on oral gratification, trying to stimulate oral intake, and continue to assess for the weight loss.
Review of the Physician's Progress Notes signed and dated by the Medical Director on 6/7/23, showed the resident was stable and seen at the request of the facility. However, there was no documentation showing the physician had addressed Resident 6's severe weight loss.
On 6/7/23 at 1358 hours, a telephone interview was conducted with RD 1. RD 1 was asked to explain the process of RD recommendations. RD 1 stated she emailed her recommendations to the DON and DSS each week. The RD stated she was not aware who was responsible to ensure her recommendations were completed. The RD was asked how she ensured her recommendations were completed. The RD stated the facility informed her either verbally or via text message when her recommendations were completed. The RD was asked what the expected time frame was to complete her recommendations. The RD stated she was not sure of the facility's policy regarding the timeliness of completing the RD recommendations, and she was not aware what an acceptable time frame was. The RD further stated she did not have time to check if her recommendations were completed.
On 6/7/23 at 1446 hours, an observation of Resident 6 was conducted. Resident 6 was in bed watching television with the head of the bed elevated. GTF pump was set at 50 cc/hr running with Jevity 1.2 and water flush was set at 50 cc/hr.
On 6/8/23 at 1015 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated when a resident experienced a significant weight loss, a change of condition form was completed, and the resident's physician and responsible party would be notified. After the review of Resident 6's weights, the DON confirmed Resident 6 experienced severe weight loss. However, the DON was unable to provide documented evidence a change of condition form was completed and the physician and responsible party were notified.
The DON was asked to explain how the RD's recommendations were received and completed. The DON stated the RD would email the recommendations to the DON who would print and give it to the desk nurse. The desk nurse would notify the physician and receive an order for the RD's recommendations. The desk nurse would then notify the resident's family. The DON stated the acceptable time frame for completion of RD recommendations was 24-72 hours from receipt. The DON added the time frame depended on the response from the physician, but the desk nurse should follow up with the physician if the physician had not responded in a timely manner. The DON stated she kept a record of completed RD recommendations. The RD recommendations from the month of April were reviewed with the DON. The DON confirmed the recommendations from the IDT Weight Variance Assessment for Resident 6 completed by RD 1 on 4/3/23, to increase the GTF [Jevity 1.2] to 65 cc/hr for 20 hours to provide 1300 cc; and 1560 kcals was not on the RD recommendation sheet until the week of 4/21-4/23/23. The DON confirmed the RD's recommendations to increase Resident 6's GTF should have been on the 4/5/23 recommendations. The DON confirmed the physician was contacted on 4/26/23, by the nurse and the physician agreed to the RD's recommendations to increase Resident 6's GTF [Jevity 1.2] to 65 cc/hr for 20 hours to provide 1300 cc, 1560 kcals. However, the DON was unable to provide documented evidence the physician's order had been transcribed and carried out.
Review of Resident 6's acute care hospital records dated 4/14/23, for Resident 6 was conducted with the DON. The DON stated Resident 6 had been transferred to the acute care hospital on 4/14/23, and readmitted to the facility on [DATE]. The DON confirmed Resident 6 was transferred to the acute care hospital due to a dislodged GT. The DON stated the nursing staff was responsible for creating or revising the existing care plan for any resident with a change of condition. The DON reviewed the nutrition care plan for Resident 6 initiated on 4/26/23, and revised 6/6/23. The care plan for Resident 6 showed Resident 6 had weight loss, but it was beneficial due to high BMI. The DON stated the nutrition care plan was revised by the RN Consultant. The DON was asked if the weight loss in the elderly was ever beneficial. The DON stated that would depend on a resident's weight goal. The DON confirmed Resident 6's care plan did not reflect Resident 6's severe weight loss between 4/1-6/1/23, or have a weight goal. The DON confirmed if a resident had a planned or beneficial weight loss, it should be coded as such in the MDS assessment. The DON further confirmed the physician should determine if the weight loss was beneficial.
On 6/8/23 at 1025 hours, a telephone interview was conducted with the RN Consultant. The RN Consultant was asked how she determined the severe weight loss for Resident 6 was beneficial. The RN stated an IDT meeting was held and Resident 6's BMI of 31 was discussed. The RN Consultant added Resident 6 was readmitted from the acute care hospital and the IDT discussed encouraging the oral intake for Resident 6. The RN Consultant stated a resident who was transitioning off an enteral feeding was expected to lose weight. The RN Consultant stated the IDT meeting was informal and she was not sure if the meeting was documented. The RN Consultant confirmed the physician and responsible party for Resident 6 were not notified regarding the plan to transition Resident 6 off the enteral feeding. The RN Consultant stated she submitted her recommendations regarding Resident 6 via email to the DON. However, the DON was unable to provide documented evidence the RN consultant had recommended Resident 6 to be transitioned off the enteral feeding.
On 6/8/23 at 1145 hours, an interview was conducted with RD 1. RD 1 confirmed she would increase the fluids for a resident with a diagnosis of fecal impaction. RD 1 confirmed the water flush for Resident 6 had not been increased and remained at 30 cc/hr for 20 hours.
On 6/8/23 at 1655 hours, an interview was conducted with the DON. The DON confirmed Resident 6 was readmitted to the facility on [DATE], with an order to weigh the resident weekly for four weeks. The DON confirmed Resident 6 was only weighed for two weeks: on 4/26/23 and 5/2/23. The DON was asked if the facility had a protocol for weekly weights for those residents who experienced a significant weight loss. The DON stated she was not sure if there was a protocol to weigh a resident weekly if the resident experienced a significant weight loss but agreed it should be a protocol and was working on improving that.
On 6/12/23 at 0925 hours, an interview was conducted with RN 1 regarding readmission of residents. RN 1 stated she was responsible for notifying the physician of the resident's readmission to the facility. RN 1 confirmed she completed the readmission for Resident 6 on 4/19/23. RN 1 confirmed Resident 6's GTF and water flush orders remained the same as of the prior admission: Jevity 1.2 at 50 cc/hr for 20 hours for 1000 ml, 1200 kcals and 30 cc/hr water flush for 20 hours.
2. Medical record review for Resident 86 was initiated on 6/5/23. Resident 86 was admitted to the facility on [DATE], with diagnoses of frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage (area of the brain that controls executive functioning skills following bleeding in the brain), gastrointestinal hemorrhage (digestive tract bleeding), type 2 diabetes mellitus (disease in which the body's ability to produce and respond to the hormone insulin is impaired), gastrostomy status (opening into the stomach from the abdominal wall made surgically for the introduction of food).
Review of Resident 86's H&P Examination dated 8/11/22, showed Resident 86 did not have the capacity to understand and make decisions.
Review of the Nutritional Risk Review Quarterly for Resident 86 completed by RD 3 on 1/25/23, showed the following:
- Current weight on 1/2/23 was 147 lbs
- Weight on 7/1/22, was 158 lbs with 11 lbs (7.48%) weight loss in six months
- Weight on 1/4/22, was 169 lbs with 22 lbs (14.97%) weight loss in 12 months
- The goal rate was Glucerna (tube feeding formula) 1.2 at 55 ml/hr for 20 hours and water flush of 35 ml/hr for 20 hours which provided 1100 ml/1320 kcals, 66 gm of protein, 886 ml of free water (total water fluids: 1766 ml) 100% DRI (dietary reference intake).
Review of the Progress Note signed and dated by Nurse Practitioner on 4/4/23, showed to continue with current medical management and continue with GT feeding as per the RD. However, there was no documentation addressing Resident 86's severe weight loss.
Review of the IDT Weight Variance Assessment for Resident 86 completed by RD 1 on 4/3/23, signed and discussed with the IDT on 4/26/23, showed the following:
- Current weight was 132 lbs
- Weight on 3/1/23 was 150 lbs with weight loss of 18 lbs (12%)
- Weight on 1/2/23 was 147 lbs with weight loss of 15 lbs (10.2%)
- The interventions/implementations showed needs to re-estimate based on actual weight of 60 kilograms: 1500-1850 kcal
- Recommend to increase GT [Glucerna 1.5] to 55 cc/hr for 20 hours for a daily total of 1000cc, 1650 kcals; and perform weekly weights for four weeks or until stable.
However, review of the RD's recommendations dated 4/5 and 4/19/23, did not include the recommendation for Resident 86 from the IDT Weight Variance Assessment to increase the GTF [Glucerna 1.5] to 55 cc/hr x 20 hours to provide 1000cc, 1650 kcals.
Review of the RD's recommendations from 4/21 to 4/23/23, for Resident 86, showed to increase Glucerna 1.5 to 55 cc/hr for 20 hours with a total of 1100 cc, 1650 kcals; increase water flushes to 50 cc/hr for 20 hours with a total of 1000 cc; and perform weekly weight for four weeks or until stable.
Review of Resident 86's Quarterly MDS dated [DATE], showed Resident 86 weighed 132 lbs and had experienced a 5% or more weight loss in the past month or 10% or more weight loss in the past six months. The MDS also showed Resident 86 was not on a physician-prescribed weight-loss regimen and was administered 51% or more of total calories through a tube feeding and 501 cc/day or more of fluid intake by tube feeding.
Review of Resident 86's Physician's Order Summary Report for the month of June 2023 showed the following order dated 4/26/23:
- To administer Glucerna 1.5 at 55 ml/hr for 20 hours for a daily total of 1100 ml/1650 kcals.
- To provide water at a minimum of 50 ml/hr for 20 hours for a total of 1000 ml.
Review of the Nutritional Risk Review Quarterly for Resident 86 initiated by RD 1 on 4/19/23, showed the resident's weight on 5/2/23 was 133.6 lbs. However, the quarterly nutritional assessment was not completed.
Review of the Progress Note signed and dated by the Nurse Practitioner on 5/2/23, showed to continue with current medical management and GT feeding as per the RD. However, there was no documentation addressing Resident 86's weight and severe weight loss.
Review of Resident 86's plan initiated by LVN 12 on 5/7/23, showed a care plan problem for altered nutritional status, malnutrition and dehydration related to impaired mobility, DM (diabetes mellitus), hypothyroidism, dysphagia (difficulty swallowing), GT (gastrostomy tube). The goal of Resident 86's care plan showed the resident will have no signs or symptoms of dehydration. The interventions/tasks showed RD assessment as indicated; weigh on admission, monthly and as indicated; and notify the physician, RD, and family of significant weight changes.
Review of the facility document titled Weights and Vitals Summary from 3/1/23 through 6/1/23, showed the following weights and comparisons for Resident 86:
* On 3/1/23, 150 lbs
* On 4/1/23, 132 lbs, -18 lbs, a 12% severe weight loss in one month [comparison weight on 3/1/23, 150 lbs]; -15 lbs, a 10% severe weight loss in three months [comparison weight on 1/2/23 147 lbs]
* On 5/2/23, 133.6 lbs, -14.4 lbs, 9.7% severe weight loss in three months [comparison weight on 2/1/23 148 lbs], -16.4 lbs
* On 6/1/23, 128.4 lbs, -21.6 lbs, 14.4% severe weight loss in three months [comparison weight 3/1/23 150 lbs]
Review of Resident 86's Physician's Orders dated 6/1/23, showed to flush GT with water at a minimum of 50 ml/hr for 20 hours for a total of 1000 ml; administer Glucerna 1.5 at 55 ml/hr for 20 hours for a daily total of 1100 ml/1650 kcals; and perform weekly weights for four weeks or until stable.
On 6/5/23 at 1103 hours, an observation of Resident 86 was conducted. Resident 86 was in bed with head of the bed elevated, GTF pump was set at 55 cc/hr with enteral feeding of Glucerna 1.5 and water flush set at 35 cc/hr. However, Resident 86 was not connected to the GTF.
Review of Resident 86's plan of care revised by the RN consultant on 6/6/23, showed a care plan problem addressing the resident required enteral regime for nutritional support. The care plan showed Resident 86's weight was WNL (within normal limits). The care plan goal was to be able to have planned weight gain. The interventions/tasks showed weight as indicated.
On 6/12/23 at 1010 hours, an interview and concurrent Resident 86's electronic medical record was conducted with the DON. The DON stated when a resident experienced a significant weight loss, a change of condition report was completed and the resident's physician and responsible party were notified. The DON confirmed Resident 86 experienced severe weight loss. The DON confirmed a change of condition report was completed on Resident 86 on 4/7/23, 4/8/23, 4/17/23, 5/8/23 and 5/25/23; however, none of the reports were related to Resident 86's severe weight loss. The DON stated the physician was notified of the RD recommendation on 4/26/23, therefore, the physician was aware of Resident 86's weight loss; however, the responsible party was not notified of Resident 86's severe weight loss between 3/1/23 and 6/1/23.
The DON confirmed on 4/3/23 the RD initiated the IDT Weight Variance Assessment and recommended to increase Resident 86's GTF [Glucerna 1.5] to 55 cc/hr for 20 hours to provide 1100 ml, 1650 kcals; and increase water flush 50 cc/hr for 20 hours for a total of 1000 cc; and weekly weights for four weeks. The DON confirmed the RD's recommendations dated 4/5 and 4/19/23, did not include the recommendation to increase Resident 86's GTF. The DON confirmed the RD's recommendations dated 4/12-4/23/23, did show the recommendation to increase Resident 86's GTF, water flush, and weekly weights. The DON confirmed an order was obtained from Resident 86's physician on 4/26/23, to increase the Resident 86's GTF and water flush; and for weekly weights for four weeks. The DON agreed the order to increase Resident 86's GTF, flush, and weekly weight for four weeks was not completed in a timely manner. The DON stated her expectation was for the RD's recommendation from the 4/3/23 IDT Weight Variance Assessment to be entered on the 4/5/23 RD recommendations.
The DON confirmed the weekly weights were ordered on 4/26/23, for Resident 86; however, Resident 86 was not weighed weekly as ordered.
The DON reviewed Resident 86's the nutritional care plan and confirmed the nutritional care plan for Resident 86 was last revised on 5/7/23, and did not reflect Resident 86's severe weight loss between 1/2/23 and 6/1/23. The DON confirmed the care plan problem addressing the enteral regime for nutritional support for Resident 86 was last revised on 6/6/23; however, it did not reflect Resident 86's severe weight loss between 1/2/23 and 6/1/23.
Cross reference to F657.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 6/7/23 at 1008 hours, a medication observation was conducted with LVN 3. LVN 3 administered Resident 83 a dose of budesoni...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 6/7/23 at 1008 hours, a medication observation was conducted with LVN 3. LVN 3 administered Resident 83 a dose of budesonide (a medication inhaled to decrease swelling in the lungs) via a nebulizer mask attached to a nebulizer machine. A clear bag was observed next to the nebulizer machine. There was no date or label observed on the nebulizer tubing, nebulizer mask, or bag.
On 6/7/23 at 1057 hours, an interview was conducted with LVN 3. LVN 3 verified there was no date or label on the nebulizer tubing, nebulizer mask, or bag for Resident 83. LVN 3 stated the nebulizer tubing, mask, and bag were changed every week and should have been labeled with the resident's name and date when they were changed.
6. Review of the facility's P&P titled Administering Medications through a Small Volume (Handheld) nebulizer revised October 2010 showed to change equipment and tubing every seven to 14 days, or according to the facility protocol or per manufacturer's guidelines.
On 6/7/23 at 0850 hours during a medication pass observation, LVN 1 was observed administering a breathing treatment to Resident 114. Resident 114's nebulizer tubing was observed undated.
Medical record review for Resident 114 was initiated on 6/7/23. Resident 114 was readmitted to the facility on [DATE].
Review Resident 114's Order Summary Report dated June 2023 showed a physician's order dated 5/23/23, to administer ipratropium- albuterol (used to treat and prevent symptoms (wheezing and shortness of breath) caused by lung disease) 0.5-2.5 mg/3 ml 3 ml inhale orally via nebulizer every four hours for SOB/wheezing administered routinely every four hours daily.
On 6/7/23 at 0856 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified there was no date labeled on Resident 114's nebulizer tubing. LVN 1 stated the nebulizer tubing should be dated.
On 6/8/23 at 0847 hours, an interview was conducted with the DON. The DON acknowledged the above findings.
Cross reference to F656, example #1.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary treatments to six of 27 final sampled residents (Residents 18, 31, 88, 92, and 114) receiving the oxygen therapy.
* The facility failed to follow the physician's order for Resident 18's oxygen therapy.
* The facility failed to ensure Residents 18, 31, 88, and 92's nasal cannula tubing was dated as per the facility's P&P. In addition, the facility failed to ensure the nasal cannula tubing was stored in a set-up bag when not in use for Resident 31.
* The facility failed to ensure Residents 83, 88, and 114's nebulizer tubing and mask were dated as per the facility's P&P.
* The facility failed to ensure Resident 31's nebulizer mask was dated. In addition, the facility failed to ensure the nebulizer mask was stored in a set-up bag when not in use.
These failures had the potential to negatively impact the residents' medical conditions.
Findings:
1. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to verify there is a physician's order for this procedure, review the physician's orders or facility protocol for oxygen administration, and replace oxygen supplies/tubings typically every seven to 14 days or per the manufacturer's guidelines.
On 6/5/23 at 0957 hours, Resident 18 was observed lying in bed with oxygen via nasal cannula which was attached to the oxygen machine setting at three liters per minute. The nasal cannula was unlabeled and undated.
Medical record review for Resident 18 was initiated on 6/6/23. Resident 18 was admitted on [DATE], and readmitted on [DATE], to the facility.
Review of Resident 18's H&P examination dated 8/4/22, showed a diagnosis of COPD.
Review of Resident 18's Order Summary Report dated June 2023 showed a physician's order dated 5/29/23, for oxygen administration at two liters per minute via nasal cannula continuously every shift for respiratory comfort.
On 6/7/23 at 1453 hours, an observation, interview, and concurrent medical record review was conducted with LVN 9. LVN 9 verified the oxygen machine was set at three liters per minute and the physician's order for the oxygen was to administer at two liters per minute continuously for Resident 18. LVN 9 verified the nasal cannula was unlabeled and undated.
On 6/12/23 at 1458 hours, an interview was conducted with the DON. The DON verified the above findings and stated the night shift nurses were responsible to change the nasal cannula once a week and it was important to change the nasal cannula for infection control purposes and to follow physician's order for oxygen administration.
2. On 6/5/23 at 1212 hours and 6/7/23 at 0833 hours, Resident 92's nasal cannula was observed unlabeled and undated.
Medical record review for Resident 92 was initiated on 6/5/23. Resident 92 was admitted on [DATE], and readmitted on [DATE] to the facility.
Review of Resident 92's Order Summary Report dated June 2023, showed a physician's order dated 6/7/23, to administer oxygen at two to three liters per minute via nasal cannula as needed for shortness of breath and to maintain oxygen saturation level greater than 90%.
On 6/7/23 at 0905 hours, an observation and concurrent interview was conducted with LVN 9. LVN 9 verified the oxygen nasal cannula tubing was not labeled with the date when it was changed. LVN 9 stated nasal cannula should have been dated and the night shift nurses were responsible to change the oxygen tubing once a week.
On 6/13/23 at 0853 hours, an interview was conducted with the DON. The DON verified the above findings and stated the night shift nurses were responsible to change the nasal cannula once a week and it was important to change nasal cannula for infection control purposes.
4. On 6/5/23 at 1010 hours and 6/7/23 at 0815 hours, Resident 88's oxygen tubing and nebulizer mask/tubing were observed with no label of the date when it was changed.
Medical record review for Resident 88 was initiated. Resident 88 was admitted to the facility on [DATE].
Review of the Order Summary Report for June 2023 showed a Physician's Order dated 3/23/23, to administer oxygen at two liters per minute via nasal cannula (a device used to deliver supplemental oxygen to a resident in need of respiratory help) as needed for oxygen saturation less than 92%. Another order dated 5/3/23 to administer budesonide inhalation duspension (a breathing treatment that works by relaxing and opening air passage to the lungs to make breathing easier) 0.5 mg/2 ml inhale orally via nebulizer two times a day.
On 6/7/23 at 0825 hours, an observation and concurrent interview for Resident 88 was conducted with LVN 5. LVN 5 verified the oxygen nasal cannula tubing and nebulizer mask/tubing were not labeled with the date when they were changed. LVN 5 stated the licensed nurse changed the oxygen tubing once a week on Sundays and the night shift staff usually changed it.
On 6/08/23 at 1016 hours, an interview and concurrent medical record review for Resident 88 was conducted with RN 2. RN 2 stated the licensed nurses changed the tubings and placed the nebulizer mask/tubing in a clear plastic bag after each use. RN 2 was informed and verified the above findings.
Cross reference to F656, example #4.
3. On 6/6/23 at 0858 hours, Resident 31 was observed seated in a wheelchair in her room and Resident 31 was observed using a nasal cannula tubing connected to a portable oxygen. The nasal cannula tubing was undated. Another nasal cannula tubing was observed connected to an oxygen concentrator near Resident 31's bed. The nasal cannula tubing connected to the oxygen concentrator was undated, and a set-up bag on the concentrator was also undated. The nasal cannula tubing was tied around the left side rail. A nebulizer mask was also observed on the bedside table and not inside a set-up bag. The nebulizer mask and tubing were also undated.
Medical record review for Resident 31 was initiated on 6/5/23. Resident 31 was initially admitted to the facility on [DATE], and readmitted on [DATE].
Review of the MDS dated [DATE], showed Resident 31 was cognitively intact.
Review of Resident 31's Order Summary Report showed the following physician's orders:
- on 2/24/23, to administer oxygen at two liters via nasal cannula routine to maintain oxygen saturation level greater than 90% every shift;
- on 2/24/23, to administer ipratropium-albuterol solution 0.5-2.5 mg 3 ml via nebulizer every six hours as needed for shortness of breath or wheezing; and
- on 5/12/23, to administer budesonide inhalation suspension 0.5 mg/2 ml 2 ml inhale orally one time a day.
Review of the PACS - Medication Administration Record showed Resident 31 was administered the following:
- oxygen at two liters per minute was administered on 6/1 to 6/8/23;
- budesonide inhalation on 6/1 to 6/8/23 at 0900 hours.
On 6/7/23 at 0940 hours, an observation and concurrent interview was conducted with Resident 31. The nose piece of the nasal cannula tubing connected to the concentrator was observed on the floor. An interview was conducted with Resident 31. Resident 31 stated she changed her nasal cannula tubing for her portable oxygen tank and oxygen concentrator by herself. Resident 31 also stated she changed her nebulizer mask and tubing by herself. Resident 31 stated she would ask the staff for new nasal cannula tubing and nebulizer mask, and she would do it herself. Resident 31 stated she had been doing this since she was a teenager. When asked when she changed the nasal cannula tubing and nebulizer mask, Resident 31 stated maybe three days ago, and she stated she would change them when she needed to.
On 6/7/23 at 0950 hours, an observation for Resident 31 and concurrent interview was conducted with LVN 9. LVN 9 verified the above findings. LVN 9 verified the nose piece of the nasal cannula tubing connected to the concentrator was on the floor, the nasal cannula tubing and set-up bag on the oxygen concentrator were undated. LVN 9 verified the nasal cannula tubing connected to the portable oxygen was undated. LVN 9 also verified the nebulizer mask was undated, and there was no set-up bag for the nebulizer mask. LVN 9 stated the nasal cannula tubing and nebulizer mask were changed weekly by the charge nurse on the 2300 to 0700 hours shift. LVN 9 stated the nasal cannula tubing and nebulizer mask had to be dated and were supposed to be in a set-up bag when not in use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 75 was initiated on 6/6/23. Resident 75 was readmitted to the facility on [DATE]. Resident...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 75 was initiated on 6/6/23. Resident 75 was readmitted to the facility on [DATE]. Resident 75 had an end stage renal disease requiring hemodialysis treatment.
Review of Resident's 75 MDS dated [DATE], showed Resident 75 had severe impairment.
Review of the Order Summary Report dated 12/26/22, showed to check AV fistula shunt for the presence of bruit and thrill upon return from dialysis and every shift.
Review of the Dialysis Care checklist dated 6/3/23, showed no documented evidence the A/V fistula was assessed for the presence of bruit and thrill as per the physician's order.
On 6/8/23 at 1538 hours, an interview and concurrent medical record review was conducted with LVN 1 and RN 2. LVN 1 and RN 2 were informed and verified the finding.
Based on observation, interview, medical record review, facility P&P review, the facility failed to provide the necessary care and services to attain and maintain the highest physical well-being for two of 27 final sampled residents (Residents 16 and 75) who required dialysis.
* The facility failed to ensure Resident 16's dialysis checklists were accurate and complete which included Resident 16's pre dialysis check list (for blood sugars, vital signs, access site, skin integrity, medications sent with resident, an special instructions) and post dialysis checklist (for vital signs, access site, skin integrity, and special instructions).
* The facility failed to ensure Resident's 75 dialysis access site was assessed for bruit and thrill as per the physician's order.
These failures had the potential risk for the residents not being provided the appropriate care and treatment, which could lead to medical complications.
Findings:
Review of the facility's P&P titled Renal Disease, Care of a Resident (undated) showed education and training of staff include the following:
- The nature and clinical management of ESRD (including infection prevention and nutritional
- The type of assessment data that is to be gathered about the resident's condition on a daily basis or per shift basis
- Signs and symptoms of worsening conditions and/or complications of ESRD
- How to recognize and intervene in medical emergencies such as hemorrhage and specific
- How to recognize and manage equipment failure or complications (according to the type of equipment used in the facility)
timing and administration of medications, particularly those before and after dialysis
- The care of grafts and fistulas
- The handling of waste
1. Review of Resident 16's medical record was initiated on 6/9/23. Resident 16 was readmitted to the facility on [DATE]. Resident 16 had an end stage renal disease requiring hemodialysis treatment.
Review of Resident 16's MDS dated [DATE], showed Resident 16 had moderate impaired cognition.
Review of Resident 16's Order Summary Report for June 2023 showed the following physician's orders dated 10/10/22:
- Dialysis every Monday, Wednesday, and Fridays at the dialysis center
- Check AV shunt on the right antecubital fossa for color, warmth, and edema every shift
- Check AV shunt for presence of bruit and thrill upon returning from dialysis and then every shift. If negative, notify the physician. Special Instructions: auscultate for bruit with stethoscope (should hear a continuous low bruit sound) and palpate for thrill (should feel a continuous vibration sensation) every shift.
Review of Resident 16's Dialysis Checklist for April, May, and June 2023 showed the following:
- There was no assessment of the access site for thrill or bruit on 4/25, 4/29, 5/6, 5/9, 5/21, and 6/1/23.
- There were incomplete post dialysis assessments on 4/18, 4/20, 5/1, 5/9, 5/11, and 6/1/23.
- There was no documentation on the location of the dialysis access site assessed on 4/1, 4/13, 4/25, 4/27, 5/18, 5/27, and 5/30/23.
- There were inaccurate documentation of the dialysis access site assessed on 4/15, 5/1, and 5/6/23.
On 6/9/23 at 1307 hours, Resident 16's room was observed with a signage of Contact/Droplet precaution posted on the door and a three-tier cart with yellow gowns, N95 mask, and gloves.
On 6/9/23 at 1311 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 16 was out for dialysis treatment. CNA 6 stated Resident 16's current dialysis schedule was on Mondays, Wednesdays, and Fridays; and would leave the facility at around 0930 hours, and returned at around 1430 hours.
On 6/9/23 at 1325 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 was informed and verified the above findings regarding the incomplete and inaccurate assessments on the facility's dialysis checklist form.
On 6/9/23 at 1440 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings.
Cross reference to F726.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. During an initial tour of the facility on 6/5/23 at 1500 hours, Resident 72 was observed in bed with the left side of the bed...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. During an initial tour of the facility on 6/5/23 at 1500 hours, Resident 72 was observed in bed with the left side of the bed against the wall. The side rails were observed elevated on both sides of the bed and a floor mat was on the right side of the bed. A bed alarm was also observed hanging from the right side rail.
Medical record review for Resident 72 was initiated on 6/7/23. Resident 72 was admitted to the facility on [DATE].
Review of the Order Summary Report as of 6/8/23, showed a physician's order dated 11/30/22, to have top half side rails up times two as an aid to bed mobility/turning and repositioning.
Review of Resident 72's MDS dated [DATE], showed Resident 72 had severe cognitive impairment and required extensive assistance from two staff for bed mobility.
However, further medical record review for Resident 72 failed to show the least restrictive alternative measure was attempted prior to the use of side rails.
On 6/12/23 at 0850 hours, an interview with CNA 4 was conducted. CNA 4 stated Resident 72 used the side rails to help prevent falls.
On 6/12/23 at 0901 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and verified the least restrictive measure was not attempted prior to the use of side rails for Resident 72. The DON acknowledged the above finding.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the least restrictive alternative measures were implemented prior to the use of side rails for six of 27 final sampled residents (Residents 21, 25, 65, 72, 115, and 727). These failures had the potential to put the residents at risk for serious injury.
Findings:
Review of the facility's P&P titled Bed Safety and Bed Rails revised August 2022 showed before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with the bed rails and obtain informed consent. The following information will be included in the consent: the assessed medical needs that will be addressed with the use of bed rails; the resident's risk from the use of bed rails and how these will be mitigated; the alternatives that were attempted but failed to meet the resident's needs; and the alternatives that were considered but not attempted and the reasons.
1. On 6/6/23 at 0921 hours, and 6/7/23 at 0906 hours, Resident 25 was observed in bed with bilateral half padded side rails elevated.
Medical record review for Resident 25 was initiated on 6/6/23. Resident 25 was readmitted to the facility on [DATE].
Review of Resident 25's MDS dated [DATE], showed Resident 25 had severe cognitive impairment and required extensive assistance of two staff for bed mobility.
Review of Resident 25's Order Summary Report for the month of June 2023 showed a physician's order dated 4/26/23, for both top half padded side rails up in bed for seizure disorder.
Review of Resident 25's admission Side/Bed Rail Evaluation/Consent dated 4/6/19, showed side rails were use for bed mobility and to assist with transfer.
However, further medical record review for Resident 25 failed to show documented evidence the least restrictive alternative measure was attempted prior to the use of side rails.
On 6/7/23 at 1357 hours, an interview was conducted with CNA 5. CNA 5 stated Resident 25 used the bed side rails to hold for bed mobility.
On 6/7/23 at 1417 hours, an interview was conducted with LVN 4. LVN 4 stated Resident 25 used the bed side rails for seizure precautions, repositioning, and bed mobility.
On 6/8/23 at 0854 hours, an interview was conducted with RN 2. RN 2 stated the use of side rails was a standard in the facility as positioning enabler. RN 2 further stated she did not know if they attempted the least restrictive alternative measure prior to the use of side rails.
On 6/8/23 at 1634 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the documentation for the least restrictive alternative measure attempted should be in the progress notes; however, the DON was unable to provide documented evidence showing the least restrictive alternative measure was attempted prior to the use of side rails for Resident 25. The DON acknowledged the above finding.
2. On 6/6/23 at 1045 hours, Resident 115 was observed in bed with the left half side rail elevated with a hanging metal basket compartment for Resident 115's wound vac machine and right half side rail down.
Medical record review for Resident 115 was initiated on 6/6/23. Resident 115 was admitted to the facility on [DATE].
Review of Resident 115's MDS dated [DATE], showed Resident 115 was cognitively intact and required limited assistance of one staff for bed mobility.
Review of Resident 115's Order Summary Report for June 2023 showed a physician's order dated 5/23/23, for both top half side rails up as an aid to bed mobility, turning, and repositioning.
Review of Resident 115's Nursing- Bed Rail Observation/assessment dated [DATE], showed the use for side rails was for safety, security, and positioning enabler.
However, further medical record review for Resident 115 failed to show documented evidence the least restrictive alternative measure was attempted prior to the use of side rails.
On 6/6/23 at 1045 hours, an interview was conducted with Resident 115. Resident 115 stated he used the bed side rail to help him turn and use the hanging metal basket compartment on the left bed side rail to hold his wound vac machine.
On 6/6/23 at 1412 hours, an interview was conducted with CNA 5. CNA 5 stated Resident 115 used the bed side rails for bed mobility.
On 6/7/23 at 1430 hours, an interview was conducted with LVN 4. LVN 4 stated Resident 115 used the bed side rails for bed mobility.
On 6/8/23 at 1634 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the documentation for the least restrictive alternative measure attempted should be in the progress notes; however, the DON was unable to provide documented evidence showing the least restrictive alternative measure was attempted prior to the use of side rails for Resident 115. The DON acknowledged the above finding.
3. On 6/6/23 at 1003 hours, and 6/7/23 at 0904 hours, Resident 727 was observed in bed with bilateral half side rails elevated.
Medical record review for Resident 727 was initiated on 6/6/23. Resident 727 was admitted in the facility on 3/17/23.
Review of Resident 727's H&P examination dated 3/18/23, showed Resident 727 had the capacity to understand and make decisions.
Review of Resident 727's MDS dated [DATE], showed Resident 727 required extensive assistance of one staff for bed mobility.
Review of Resident 727's Order Summary Report for June 2023 showed a physician's order dated 3/18/23, for both top half side rails up as an aid to bed mobility, turning, and repositioning.
Review of Resident 727's Nursing- Bed Rail Observation/assessment dated [DATE], showed the use of the side rails was for safety, security, and positioning enabler.
However, further medical record review for Resident 727 failed to show documented evidence the least restrictive alternative measure was attempted prior to the use of side rails.
On 6/7/23 at 1406 hours, an interview was conducted with CNA 5. CNA 5 stated Resident 727 used the bed side rails to hold on to move from side to side and to pull himself up in bed.
On 6/7/23 at 1423 hours, an interview was conducted with LVN 4. LVN 4 stated Resident 727 used the bed side rails to help with turning and repositioning.
On 6/8/23 at 1634 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the documentation on the least restrictive alternative measure attempted should be in the progress notes; however, the DON was unable to provide documented evidence showing the least restrictive alternative measure was attempted prior to the use of side rails for Resident 727. The DON acknowledged the above finding.
5. On 6/5/23 at 0931 hours, and 6/7/23 at 0902 hours, Resident 65 was observed in bed with both half side rails elevated.
Medical record review for Resident 65 was initiated on 6/6/23. Resident 65 was admitted in the facility on 12/9/19.
Review of Resident 65's MDS dated [DATE], showed Resident 65 required extensive assistance of one staff for bed mobility.
Review of Resident 65's Order Summary Report for June 2023 showed a physician's order dated 4/18/22, for padded top half side rails up to both side of the bed for safety/mobility (seizure disorder).
Review of the Side Rail Evaluation/Consent dated 12/9/19, under the section evaluation for use of side rails, showed the alternatives attempted prior to side rails application were the adjustable bed and padded top half side rails for safety. However, further medical record review for Resident 65 failed to show the least restrictive alternative measure was attempted prior to the use of side rails.
On 6/7/23 at 0907 hours, an observation and concurrent interview was conducted with CNA 7. CNA 7 stated Resident 65 used the bed side rails to hold on to move from side to side in bed.
On 6/9/23 at 1631 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated during assessment, there should be the least restrictive measure attempted prior to the use of bed rails. The DON was informed and verified there was no least restrictive intervention attempted prior to use of the bed side rails for Resident 65.
4. On 6/6/23 at 0911 hours, on 6/7/23 at 0930 and 1442 hours, on 6/8/23 at 1008 hours, Resident 21 was observed lying in bed with bilateral side rails elevated.
Medical record review for Resident 21 was initiated on 6/5/23. Resident 21 was admitted to the facility on [DATE].
Review of Resident 21's MDS dated 419/23, showed Resident 21 had severe cognitive impairment and required extensive assistance from one staff for bed mobility.
Review of Resident 21's Order Summary Report showed a physician's order dated 4/13/23, for both top half side rails as an aid to bed mobility, turning, and repositioning.
Review of Resident 21's Nursing - Bed Rail Observation/ assessment dated [DATE], showed side rails were considered for positioning enabler, and would assist Resident 21 with bed mobility and transfer. However, the assessment did not show any less restrictive measure was attempted prior to the use of side rails.
Further review of the medical record showed no documented evidence a least restrictive alternative was attempted prior to the use of the side rails.
On 6/8/23 at 1009 hours, an interview was conducted with CNA 9. When asked about Resident 21's use of side rails, CNA 9 stated Resident 21 could move her arms and grabbed the side rails during turning and repositioning.
On 6/8/23 at 1115 hours, an interview and concurrent medical record review was conducted with RN 2. When asked about the side rails, RN 2 stated the facility put the side rails for all residents upon admission as a standard procedure. RN 2 stated the facility would assess the residents as part of the procedure. When asked about least restrictive measures, RN 2 verified there was no least restrictive measures attempted prior to Resident 21's use of side rails.
On 6/8/23 at 1635 hours, an interview and concurrent medical record review for Resident 21 was conducted with the DON. When asked about the side rails, the DON stated a side rail assessment was completed upon admission, and least restrictive measures, such as placing the bed in lowest position, were also conducted prior to side rail use. The DON stated the documentation for the least restrictive alternative measure attempted should be in the progress notes. When asked for the documentation of the least restrictive alternative measures prior to the use of side rails for Resident 21, the DON was unable to provide any documentation. The DON verified the above finding.
Cross reference to F909, example #5.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Hemodialysis Access Care revised September 2010 showed for the care of AVFs and AVGs and ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Hemodialysis Access Care revised September 2010 showed for the care of AVFs and AVGs and to prevent infections and/or clotting, the nursing staff is to check patency of the site at regular intervals; and to palpate the site to feel for the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access.
Review of Resident 16 medical record was initiated on 6/9/23. Resident 16 was readmitted to the facility on [DATE]. Resident 16 had an end stage renal disease requiring the resident to undergo hemodialysis treatment.
Review of Resident 16's Order Summary Report for June 2023 showed a physician's order dated 10/10/22, to assess the resident's AV shunt for the presence of bruit and thrill upon return from dialysis, then every shift; if negative, notify the MD. Special instructions included to auscultate for bruit with stethoscope (should hear a continuous bruit sound) and palpate for thrill (should hear a continuous vibration sensation) every shift.
On 6/9/23 at 1401 hours, an interview was conducted with RN 2 regarding Resident 16's dialysis access site assessment. When asked how the staff would assess Resident 16's dialysis access site, RN 2 was unable to verbalize the steps to assess Resident 16's dialysis site. RN 2 stated she did not know.
Review of RN 2's employee files showed RN 2 was hired to the facility on 3/21/23.
On 6/9/23 at 1420 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above finding.
On 6/12/23 at 1353 hours, an interview was conducted with the Regional DSD/IP Specialist. The Regional DSD/IP Specialist stated for a RN Supervisor or any licensed nurses working the facility, they needed skills to perform the resident's care such as medication administration with the different routes, management of G-tube, communication to the physicians, residents, and residents' representatives, proper documentation, carrying out orders, and taking care of dialysis residents. The Regional DSD/IP Specialist stated the licensed nurses required knowledge and training of how to access for the resident's dialysis access site, how to communicate changes in the resident with the dialysis center, and how to assess for possible complications in residents with dialysis treatments. The Regional DSD/IP Specialist further stated it was important to know basic skills on how to take care of residents with dialysis treatment because these residents were immunocompromised and their conditions could quickly change. When the Regional DSD/IP Specialist was ask to show documentation of RN 2's competency skills upon hire, the Regional DSD/IP Specialist stated RN 2 did not have one and the facility's skills competency form did not include the dialysis care.
Cross reference to F698, example #1.
Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the licensed nurses had specific competencies and standard of practice skill sets needed to provide the safe and efficient nursing care to the residents as evidenced by:
* LVN 9 was unable to demonstrate competency in the administration of insulin injection subcutaneously to one of 21 nonsampled residents ( Resident 23). In addition, there was no documented evidence the annual competency skills checklist for LVN 9 was completed.
* The facility failed to ensure RN 2 had the appropriate competency and skill set to assess for one of 27 final sampled residents (Resident 16)'s dialysis access site. This had the potential risk of an adverse outcome in Resident 16's care or services.
These failures had the potential to put the residents at risk for care not provided in a safe and competent manner.
Findings:
Review of the facility's P&P titled Staffing, Sufficient, and Competency Nursing revised 8/2023, showed staff must demonstrate the skills and techniques necessary to care for the resident needs including (but not limited to) the care areas of the basic nursing skills.
1. On 6/7/23 at 0806 hours, a medication administration observation for Resident 23 was conducted with LVN 9. LVN 9 was seen administering the Lantus (long-acting insulin) injection to Resident 23's right deltoid area.
Medical record review for Resident 23 was conducted on 6/5/23. Resident 23 was admitted to the facility on [DATE].
Review of Resident 23's Order Summary Report for June 2023 showed the following physician's orders dated:
- on 5/15/23, to administer Lantus SoloStar pen-injector 15 units subcutaneously two times a day; and
- on 9/1/22, to administer Humalog solution (fast-acting insulin) per sliding scale, inject subcutaneously before meals.
Review of Resident 23's PACS-Medication Administration Record for June 2023 showed LVN 9 administered the lantus injection on 6/6 and 6/7/23 at 0900 hours, on the deltoid area, and the Humalog injection on 6/6/23 at 1130 hours, on the deltoid area.
On 6/7/23 at 1112 hours, an interview and concurrent medical record review for Resident 23 was conducted with LVN 9. LVN 9 verified she gave the lantus and Humalog insulin injections on the deltoid area of Resident 23's right arm and documented in the eMAR. LVN 9 acknowledged the deltoid area was intended for the intramuscular injection site and not an injection site for medications to be given subcutaneously as the route was for the insulin medications.
On 6/12/23 at 1051 hours, an interview was conducted with the Regional DSD/IP Specialist. When the Regional DSD/IP Specialist was asked to provide a copy of the competency or skills check list form for LVN 9, the Regional DSD/ IP Specialist could not provide a documented evidence of a competency or skills check program to evaluate LVN 9 on an ongoing basis.
Cross reference to F759, example #5.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's P&P titled Medication Administration - General Guidelines undated showed the medications are adminis...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's P&P titled Medication Administration - General Guidelines undated showed the medications are administered within 60 minutes of scheduled time (one hour before and one hour after), except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility.
On 6/7/23 at 1340 hours, LVN 3 was observed beside her medication cart next to the nurses' station. LVN 3 stated she was not done with her morning medication pass and still needed to pass the medications for four more residents, two residents in Room C (Residents 33 and 125), and two residents in Room D (Residents 99 and 929). LVN 3 stated she was stuck in another room and did not ask other staff for assistance with passing the resident's medications. LVN 3 verified the morning medications should be administered within one hour before or one hour after of the due time at 9 AM.
On 6/7/23 at 1503 hours, an interview was conducted with the DON. The DON verified for medications due at 0900 hours, the medication should be given an hour before or an hour after it was due. The DON stated she was not sure why the medications were late since there were two desk nurses to help at the nurses' station.
Review of the medical records for Residents 33, 99, 125, and 929 showed the scheduled medications were not administered to these residents timely.
a. Medical record review for Resident 33 was initiated on 6/7/23. Resident 33 was admitted to the facility on [DATE].
Review of Resident 33's Medication Audit Report dated 6/7/23, showed Resident 33 had two medications and six supplements scheduled at 0900 hours. However, the 0900 hours medications were administered more than six hours later. For example, Resident 33 had Plavix (a blood thinning medication) 75 mg scheduled at 0900 hours, but it was administered at 1545 hours.
b. Medical record review for Resident 125 was initiated on 6/7/23. Resident 125 was admitted to the facility on [DATE].
Review of Resident 125's Medication Audit Report dated 6/7/23, showed Resident 125 had eight medications and four supplements scheduled at 0900 hours. However, the 0900 hours medications were administered between 1455 and 1540 hours. Resident 125's 0900 hours medication included heart medications such as amiodarone (a medication taken to prevent abnormal heart rhythm), metoprolol (a medication used to decrease blood pressure), and sacubitril-valsartan (a medication used to improve heart function).
c. Medical record review for Resident 99 was initiated on 6/7/23. Resident 99 was admitted to the facility on [DATE].
Review of Resident 99's Medication Audit Report dated 6/7/23, showed Resident 99 had six medications and one supplement scheduled at 0900 hours. However, the 0900 hours medications were administered between 1453 and 1552 hours (more than five hours late).
d. Medical record review for Resident 929 was initiated on 6/7/23. Resident 929 was admitted to the facility on [DATE].
Review of Resident 929's Medication Audit Report dated 6/7/23, showed Resident 929 had seven medications scheduled at 0900 hours. However, the 0900 hours medications were administered between 1453 and 1802 hours (more than five hours late).
4. Review of the facility's P&P titled Controlled Substances revised November 2022 showed the medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of the therapy is met.
On 6/8/23 at 1446 hours, during Medication Cart A inspection and concurrent review of the controlled drug record, Resident 118's controlled drug record for lorazepam (Ativan, an antianxiety medication) showed documentation of two tablets removed from the medication bubble pack on 5/23/23 at 2035 hours.
Medical record review for Resident 118 was initiated on 6/12/23. Resident 118 was admitted to the facility on [DATE].
Review of Resident 118's H&P examination dated 5/27/23, showed Resident 118 had the capacity to understand and make decisions.
Review of Resident 118's Order Summary Report for May 2023 showed a physician's order dated 5/18/23, to administer lorazepam 0.5 mg one tablet by mouth as needed for anxiety manifested by verbalization of anxiety for 14 days at bedtime.
Review of Resident 118's MAR dated June 2023 showed only one tablet of lorazepam 0.5 mg was administered on 5/23/23 at 2035 hours. There was no documented evidence to explain why two tablets were removed from the bubble pack on 5/23/23 at 2035 hours, while the documentation showed one tablet was administered as per the MAR.
On 6/8/23 at 1433 hours, an interview and concurrent facility document review was conducted with LVN 11. LVN 11 verified the above findings and stated the order for lorazepam was to take only one tablet for 24 hours as needed.
On 6/9/23 at 0901 hours, an interview and concurrent facility document review was conducted with the DON. The DON was informed and acknowledged the above findings.
Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide pharmaceutical services to ensure accurate reconciliation, administration and disposal as evidenced by:
* The facility failed to ensure administration of the controlled medications for one of 27 final sampled residents (Resident 112), and two nonsampled residents (Residents 9 and 73) were accurately documented to ensure accurate reconciliation and to prevent the medication administration errors. These failures posed the risk for diversion of controlled medications and medication administration errors.
* The facility failed to ensure the discontinued controlled medications for Residents 72, 99, 107, 112, 377, and 378 were removed from the current medication supply and disposed of.
* The facility failed to ensure non-controlled medications were discarded by two licensed nurses.
* The facility failed to ensure administration of antianxiety medication for Resident 118 was accurately documented to ensure accurate reconciliation and prevent medication administration errors. This failure had the potential risk for diversion of controlled medications and medication administration errors.
*The facility failed to ensure the medications were administered in a timely manner for Residents 33, 99, 125, and 929. Residents 33, 99, 125, and 929 received their morning medications five to nine hours later than the schedule times. These failures had the potential for the residents' medical needs to go untreated.
Findings:
Review of the facility's P&P titled Medication Labeling and Storage revised 2/2023 showed the following:
- If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items; and
- If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.
Review of the facility's P&P titled Medication Destruction (undated) showed discontinued medications and medications left in the facility after a resident's discharge are destroyed. Non-controlled medication destruction occurs in the presence of two licensed nurses.
1. On 6/8/23 at 1427 hours, an inspection of Medication Cart A, concurrent interview, and medical record review was conducted with LVN 4. The following was observed:
a. A bubble pack of oxycodone-apap 10-325 mg (narcotic medication used treat moderate to severe pain) for Resident 9 was counted with LVN 4. There were 44 tablets left in the bubble pack.
Review of Resident 5's Controlled Drug Record for oxycodone-apap 10-325 mg showed the following:
-Two tablets were removed on 6/3/23 at 1114 hours; and
-Two tablets were removed on 6/4/23 at 2100 hours.
Review of Resident 5's PACS - Medication Administration Record for oxycodone-apap 10-325 mg showed the following:
- only one tablet of oxycodone-apap 10-325 mg was administered to Resident 9 on 6/3/23 at 1114 hours; and
- there was no documentation the two tablets of oxycodone-apap 10-325 mg were administered to Resident 9 on 6/4/23 at 2100 hours.
b. A bottle of morphine sulfate solution (narcotic medication used to treat moderate to severe pain) for Resident 112 was observed with LVN 4. The remaining quantity of morphine sulfate in the bottle was 14 ml.
Review of Resident 112's Controlled Liquid Medication Count Sheet showed 0.5 ml of morphine sulfate was removed from the bottle on 5/25/23 at 1200 hours.
Review of Resident 112's PACS - Medication Administration Record did not show Resident 112 was administered morphine sulfate on 5/25/23.
c. A bubble pack of hydrocodone-apap 5-325 mg (narcotic medication used to treat moderate to severe pain) for Resident 73 was counted with LVN 4. There were 10 tablets left in the bubble pack.
Review of Resident 73's Drug Control Receipt/ Record/ Disposition Form for hydrocodone-apap 5-325 mg showed the following:
-one tablet was removed on 4/28/23;
-one tablet was removed on 5/4/23; and
-one tablet was removed on 6/4/23, with a note wasted. Only one signature was observed on the form.
Review of Resident 73's PACS - Medication Administration Record for hydrocodone-apap 5-325 mg did not show Resident 73 was administered hydrocodone-apap 5-325 mg on 4/28, 5/4, and 6/4/23.
LVN 4 verified the above findings.
On 6/9/23 at 1400 hours, an interview and concurrent medical record review for Residents 9, 73, and 112. The DON verified the above findings. When asked about administration of the controlled medication, the DON stated the licensed nurses were supposed to sign the count sheet and medication administration record. When asked about wastage of controlled medication, the DON stated the wastage should be done in the presence of two licensed nurses and the two licensed nurses should sign the controlled medication count sheet.
2. The following were also observed during an inspection of Medication Cart A, concurrent interview, and medical record review conducted with LVN 4:
a. Bubble packs of morphine sulfate, methadone (narcotic medication used to treat moderate to severe pain); and hydrocodone medications were observed for Resident 377.
Review of Resident 377's medical record showed a physician's order dated 6/5/23, may pick-up remains by the mortuary.
b. A bubble pack of lorazepam (antianxiety) medications for Resident 99.
Review of Resident 99's Order Summary Report showed a physician's order dated 4/26/23, to administer lorazepam 0.5 mg every six hours as needed for anxiety for 14 days (end date 5/10/23).
c. A bubble pack of lorazepam medications for Resident 378.
Review of Resident 378's Order Summary Report showed a physician's order dated 5/5/23, to administer lorazepam 0.5 mg every six hours as needed for anxiety for 14 days (end date 5/19/23).
d. Two bubble packs of zolpidem titrate 5 mg (sedative, used to treat insomnia or difficulty falling asleep), and alprazolam 0.25 mg (sedative) for Resident 112.
Review of Resident 112's medical record showed the physician's orders dated:
- On 4/10/23, to discontinue Xanax (brand name for alprazolam) 0.25 mg; and
- On 4/21/23, to discontinue Ambien (brand name for zolpidem tritate) 5 mg.
e. A bubble pack of lorazepam 1 mg for Resident 72.
Review of Resident 72's medical record showed a physician's order dated 4/28/23, to administer lorazepam 0.5 mg via GT every six hours as needed for anxiety for 30 days (discontinue date 5/28/23)
f. A bubble pack of clonazepam (sedative) 1 mg for Resident 107.
Review of Resident 107's medical record showed a physician's order dated 4/26/23, to administer clonazepam 1 mg every eight hours as needed for anxiety for 14 days, until 5/10/23.
LVN 4 verified the above findings. LVN 4 stated the discontinued controlled medications were kept in the medication cart and the licensed nurse should have been given them to the DON for destruction.
3. On 6/9/23 at 0801 hours, an interview and facility document review was conducted with RN 2. When asked about disposal of the non-controlled medications, RN 2 stated the licensed nurses remove the sticker from the bubble packs, placed them in the drug disposition record, record the quantity of the medication to be disposed and then discard the medications into a bin. RN 2 stated the drug disposition record should be signed by two licensed nurses.
Review of the Drug Disposition Record showed non-controlled medications were disposed on 6/2, 7/22, 8/24, 10/2/21, 3/26/22, 1/26, and 6/4/23, but were only signed by one licensed nurse.
RN 2 verified the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure three of 27 ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure three of 27 final sampled residents (Residents 2, 72, and 118) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior).
* The facility failed to ensure Resident 72 was not prescribed quetiapine fumarate (antipsychotic medication) unless the medication was necessary to treat a specific condition or diagnosis. In addition, the facility failed to monitor Resident 72's target behavior for the use of quetiapine fumarate and failed to evaluate whether a GDR should be attempted as per the Pharmacy Consultant's recommendation.
* The facility failed to ensure Resident 2's target behavior for the use of Seroquel (quetiapine fumarate) was monitored accurately.
* The facility failed to ensure Resident 118's hours of sleep and response to eszopiclone (a medication to treat certain sleeping problems) were monitored as per the resident's plan of care.
These failures had the potential to place the residents at risk for receiving unnecessary medications and increased risk of serious medication adverse reactions, including death.
Findings:
Review of the FDA black box warning for prescribing Seroquel (quetiapine fumarate), indicated elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel is not approved for elderly patients with dementia-related psychosis.
Review of the facility's P&P titled Antipsychotic Medication Use revised December 2016 showed the residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness of and indications for use. Antipsychotic medications shall generally be used only for conditions/diagnoses as documented in the record i.e. psychosis in the absence of dementia. The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences.
Review of the facility's P&P titled Tapering Medications and Gradual Drug Dose Reduction, revised 4/2007, showed the residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. For any individual who is receiving and antipsychotic medication to treat behavioral symptoms related to dementia, the GDR may be considered clinically contraindicated if the physician had documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior.
1. Medical record review for Resident 72 was initiated on 6/7/2023. Resident 72 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia with psychotic disturbance.
Review of Resident 72's H&P examination from the hospital dated 11/25/22, showed Resident 72 had been taking Seroquel 100 mg once a day prior to hospitalization; however, there was no specific condition or diagnosis documented in the H&P examination for the use of Seroquel medication.
Review of Resident 72's H&P examination dated 12/1/22, indicated Resident 72 had diagnoses of fall and bilateral subdural hematoma (a bleed which occurred in the space between the brain and the skull). However, there was no documentation on the clinical rationale for continuing Resident 72's Seroquel.
Review of Resident 72's Order Summary Report of discontinued physician orders showed an admission order dated 12/1/22, to administer quetiapine fumarate (Seroquel) 100 mg tablet once a day for psychosis manifested by resistive to care; an order dated 12/9/22, to administer quetiapine fumarate 50 mg tablet every 8 hours as needed for agitation; and an order dated 12/19/22, to administer quetiapine fumarate 100 mg tablet twice a day for psychosis manifested by physical combativeness with care.
Review of Resident 72's Order Summary Report for June 2023 showed a physician's order dated 12/20/22, to administer quetiapine fumarate 100 mg tablet two times a day for psychosis manifested by physical combativeness with care; and another order dated 12/20/22, to monitor episodes of psychosis as evidenced by physical combativeness during care for the drug quetiapine.
Review of Resident 72's Nurse Practitioner Notes dated 12/2, 12/7, 12/9, 12/12, 12/15, 12/19, 12/23, 12/27, and 12/30/22, showed there were no changes to the current plan of care. However, there was no documentation explaining why the quetiapine medication was continued upon admission to the facility and why the dose was doubled on 12/19/22.
Review of Resident 72's Consultant Pharmacist's Medication Regimen Review dated 12/4/22, showed as per CMS regulations, before a patient with organic mental syndrome can be started on an antipsychotic drug(s), a measurable behavior(s) must be identified which is persistent, presents a danger to him/herself or others, and causes the resident distress or functional impairment. Please clarify the behavior(s) for the resident's order for quetiapine. Resistance to care may not be considered appropriate. The document showed a follow-through for the recommendation was done; however, there was no documentation on what action was taken and there was no changes to Resident 72's medication.
Review of Resident 72's MAR for December 2022 showed from 12/1/22 to 12/20/22, Resident 72 had a total of eight episodes of psychosis manifested by resistance to care. However, from 12/20/22 to 12/31/22, there was no documented evidence Resident 72's target behavior for the use of quetiapine medication was monitored.
Review of Resident 72's MDS dated [DATE], showed Resident 72 had no potential indicators of psychosis and no behavioral symptoms exhibited which included physical and verbal behavioral symptoms and rejection of care.
Review of the note to the Attending Physician/Prescriber dated 3/6/23, showed the Pharmacy Consultant documented Resident 72 had continued on Seroquel (quetiapine) 100 mg twice a day and a GDR must be attempted unless contraindicated. A check marked to show a GDR was clinically contraindicated and signed by the prescriber on 5/18/23. However, the prescriber failed to document the clinical rationale why a GDR of quetiapine was clinically contraindicated.
Further review of Resident 72's medical record failed to show a monthly Psychotropic Summary Sheet for behavior monitoring for the use of quetiapine fumarate was completed from 12/2022 through 4/2023.
Review of the Pharmacy Medication Review signed 5/2/23, showed Resident 72 did not exhibit any significant episode or behavior this month; however, the IDT agreed for the resident to continue with current medication regimen at this time and to be seen by the psychiatrist as needed. However, there was no documented evidence a psychiatrist was consulted.
Review of Resident 72's MAR for June 2023 failed to show documented evidence Resident 72's target behavior for the use of quetiapine was monitored.
On 6/12/23 at 0845 hours, Resident 72 was observed in her room lying in bed. Resident 72's bed was observed to be against the wall, bilateral upper bed rails and a bed alarm were in place, and a floor mat was next to the bed.
On 6/12/23 at 0901 hours, an interview was conducted with the DON. The DON stated Resident 72 was redirectable, had no behavioral issues, and would try to get out of bed unassisted at times.
On 6/13/23 at 0924 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated Resident 72 was administered Seroquel for psychosis manifested by physical combativeness during care. LVN 3 stated Resident 72 had behavioral issues such as getting out of bed unassisted; however, that behavior would not considered as physically combative.
On 6/13/23 at 0949 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated Resident 72 was admitted with a diagnosis of psychosis and on admission, Resident 72 had a lot of falls in which they implemented a lot of safety measures for. RN 1 acknowledged Resident 72 was continuing to fall frequently. RN 1 stated a psychiatric evaluation was usually completed when a psychotropic medication was to be increased. However, RN 1 verified there was no documented evidence of an evaluation by the prescriber when Seroquel was increased on 12/19/22.
On 6/13/23 at 1109 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated there was no monthly behavior monitoring record for Resident 72 from December 2022 through March 2023. The DON stated there was no system in place for behavior monitoring and she started the monitoring in April 2023 using the Psychotropic Summary Sheet. However, upon medical record review, the DON was unable to provide documented evidence Resident 72's target behavior for the use of Seroquel was monitored.
On 6/13/23 at 1201 hours, a follow-up interview and concurrent medical record review was conducted with the DON. The DON verified the H&P examination did not include any diagnosis for prescribing Seroquel and verified there was no documented evidence an evaluation was completed prior to the increase of Resident 72's Seroquel dose on 12/19/22. The DON also acknowledged there was no psychiatric evaluation completed for Resident 72 and there was no documentation from the prescriber explaining why a GDR should not be attempted.
On 6/13/23 at 1555 hours, an interview was conducted with Nurse Practitioner 2. When asked what his process was for prescribing psychotropic medications, Nurse Practitioner 2 stated he would not start the resident on antipsychotic medications until they were evaluated by a psychiatrist; and to increase the dose, he would need to have a psychiatrist's recommendation. Nurse Practitioner 2 stated he reviewed the GDR recommendation for Resident 72 and he would always go by the recommendation from the pharmacist. When asked what the clinical indication for increasing Resident 72's dose of Seroquel dose was, Nurse Practitioner 2 stated Resident 72 was having an increase in behaviors according to the nurses and stated he must have been notified by the nurses that the dose was incorrect.
2. Medical record review for Resident 2 was initiated on 6/5/23. Resident 2 was admitted to the facility on [DATE].
Review of the Order Summary Report dated 6/12/23, showed a physician's orders dated 2/26/23, for Seroquel (brand name for quetiapine fumarate) 200 mg by mouth at bedtime for bipolar disorder (a mental disorder that causes dramatic shifts in a person's mood or energy, and may affect the ability to think clearly) manifested by rapid mood fluctuations; and an order dated 5/17/23, to monitor episodes of bipolar disorder manifested by rapid mood fluctuations and tally by hashmarks every shift for Seroquel use. However, the physician's orders failed to specify what rapid mood fluctuations should be monitored.
On 6/12/23 at 1431 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 stated Resident 2 was taking Seroquel for bipolar disorder manifested by rapid mood fluctuations. When asked how the staff were monitoring Resident 2's rapid mood fluctuations, LVN 7 stated she would monitor if Resident 2 was upset, yelling, screaming at the staff, having outbursts, and crying. LVN 7 stated she did not how other nurses would interpret the monitoring of rapid mood fluctuations and acknowledged the physician's order for monitoring behavioral manifestations would need to be specific.
On 6/12/23 at 1448 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked how the staff monitored Resident 2's rapid mood fluctuations. The DON stated monitoring should be for a specific behavior and verified the Resident 2's physician's order for Seroquel 200 mg was not clear or specific.
3. Review of the facility's P&P titled Psychotropic Medication Use revised July 2022, showed the attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of psychotropic medications.
Medical record review for Resident 118 was initiated on 6/12/23. Resident 118 was admitted to the facility on [DATE].
Review of Resident 118's H&P examination dated 5/27/23, showed Resident 118 had the capacity to understand and make decisions.
Review of Resident 118's Order Summary Report for June 2023 showed a physician's order dated 6/2/23, to administer eszopiclone oral tablet 3 mg one tablet by mouth every 24 hours as needed for insomnia manifested by inability to sleep for 30 days.
Review of Resident 118's plan of care dated 5/6/23, showed a care plan problem addressing insomnia. The interventions included to observe the resident's ability to sleep and respond to medication.
Review of the Resident 118's MAR dated June 2023, showed eszopiclone 3 mg was administered on 6/4, 6/5, 6/6, and 6/7/23.
However, further medical record review for Resident 118 failed to did not show documented evidence the resident's hours of sleep and response to the eszopiclone medication were monitored as per the resident's plan of care.
On 6/12/23 at 0927 hours, an interview and concurrent medical record review was conducted with MDS Coordinator 1. MDS Coordinator 1 stated the behavior monitoring should include monitoring hours of sleep during the afternoon and evening shifts; however, she was unable to provide documented evidence Resident 118's hours of sleep and response to eszopiclone medication were monitored. MDS Coordinator 1 verified the above finding.
On 6/12/23 at 1015 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was informed and verified the above finding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12.5%. Three of three licensed nurses (LVNs 1, 3, and 9) who were observed during the medication administration were found to have made errors.
* LVN 3 administered the metoprolol (blood pressure medication) oral tablet without food when the pharmacy placed an alert to administer the medication with food on the medication packaging and without checking the heart rate as per the physician's order.
* LVN 3 administered the budesonide nebulizer (medication to decrease inflammation in the lungs) and did not have Resident 83 rinse mouth after nebulizer was administered as per the medication label instruction.
* LVN 9 administered the Lantus (long-acting insulin) injection pen (prefilled devices that combine the insulin container and syringe) via intramuscular (IM, situated or taking place within, or administered into, a muscle) instead of subcutaneous (SQ or SC, situated or applied under the skin, into the fatty tissue) route.
* Resident 67 had the physician's order for Nephro-Vite ([NAME]-Vite, a supplement to treat or prevent vitamin deficiency due to poor diet or certain illnesses). However, LVN 1 administered Vitamin B-Complex which was not equivalent to the ingredients of Nephrovite.
These failures had the potential to negatively affect the residents' health conditions.
Findings:
1.a. On 6/7/23 at 0926 hours, a medication administration observation for Resident 28 was conducted with LVN 3. While LVN 3 was preparing Resident 28's morning medications, Resident 28's metoprolol bubble pack with a pharmacy label was observed and showed the following: metoprolol tartrate 25 mg one-half tablet by mouth two times a day and a pharmacy alert in red showed to give the medication with or after food. However, LVN 3 administered the medication to Resident 28 without food.
Medical record review for Resident 28 was initiated on 6/7/23. Resident 28 was admitted to the facility on [DATE].
Review of Resident 28's Order Summary Report showed a physician's order dated 5/23/23, to administer metoprolol tartrate tablet 12.5 mg tablet by mouth two times a day for hypertension.
On 6/7/23 at 1328 hours, an observation and concurrent interview for Resident 28 was conducted with LVN 3. LVN 3 verified the medication should have been given with breakfast and was not given properly.
b. On 6/7/23 at 0926 hours, a medication administration observation for Resident 28 was conducted with LVN 3. While LVN 3 was preparing Resident 28's morning medications, Resident 25's metoprolol bubble pack with a pharmacy label was observed and showed the following: metoprolol tartrate 25 mg one-half tablet by mouth two times a day and to hold for SBP (systolic blood pressure) <110 mmHg or HR (heart rate) less than 60 beats per minute. LVN 3 was observed taking Resident 28's blood pressure; however, LVN 3 was observed not checking Resident 28's heart rate.
Review of Resident 28's Order Summary Report showed a physician's order dated 5/23/23, to administer metoprolol tartrate tablet 12.5 mg tablet by mouth two times a day for hypertension, hold for SBP <110 mmHg, HR <60 beats per minute.
On 6/7/23 at 1008 hours, a concurrent interview and medical record review for Resident 28 was conducted with LVN 3. LVN 3 stated she acknowledged she did not check the heart rate for Resident 28's metoprolol medication and should have checked it prior to giving it.
2. Medical record review for Resident 83 was initiated on 6/5/23. Resident 83 was readmitted to the facility on [DATE].
Review of Resident 83's Order Summary Report showed a physician's order dated 4/28/23, for budesonide inhalation suspension 0.5 mg/2 ml 2 ml inhale orally two times a day for COPD (chronic obstructive pulmonary disease, a chronic disease which affects the lungs).
On 6/7/23 at 1008 hours, a medication administration observation for Resident 83 was conducted with LVN 3. While LVN 3 was preparing Resident 83's budesonide medication, a red pharmacy alert label on the bubble pack was observed showing the instruction to rinse mouth thoroughly after each use. LVN 3 prepared and administered the medication to Resident 83; however, LVN 3 did not instruct Resident 83 to rinse her mouth after administered the medication.
On 6/7/23 at 1328 hours, an observation and concurrent interview for Resident 83 was conducted with LVN 3. LVN 3 verified Resident 83 did not rinse her mouth after the budesonide was given .
4. Review of the facility's P&P titled IIA2: Medication Administration-General Guidelines undated showed medication are administered in accordance with written orders of the attending physician.
On 6/7/23 at 0806 hours, a medication administration observation for Resident 67 was conducted with LVN 1. LVN 1 administered Resident 67's one crushed tablet of Vitamin B complex mixed with apple sauce by mouth.
However, review of Resident 67's Order Summary Report for June 2023 showed a physician's order dated 7/22/22, to administer Nephro-Vite Tablet 0.8 mg (B Complex-C-Folic Acid) one tablet by mouth one time a day for supplement.
Review of the Plus Pharma Vitamin B-Complex house supply bottle's label showed the components of Vitamin B-Complex did not include vitamin C and folic acid.
On 6/7/34 at 1348 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 67's order was for Nephro-Vite Tablet 0.8 mg (B Complex-C-Folic Acid), but she gave a tablet from a bottle of Vitamin Complex which did not have the same equivalent components of Nephro-Vite.
On 6/8/23 at 0847 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.
3. On 6/7/23 at 0806 hours, a medication administration observation for Resident 23 was conducted with LVN 9. LVN 9 was observed administering the Lantus injection to Resident 23's deltoid area.
Review of the facility's P&P titled Insulin Administration revised 9/2014 showed insulin may be injected into the subscutaneous tissue of the upper arm, and the anterior or lateral area of the thighs and abdomen.
Medical record review for Resident 23 was conducted on 6/5/23. Resident 23 was admitted to the facility on [DATE].
Review of Resident 23's Order Summary Report showed a physician's order dated 5/15/23, to administer Lantus SoloStar pen-injector 15 units subcutaneously two times a day.
Review of Resident 23's PACS-MAR showed Resident 23 was administered Lantus injection on 6/7/23 at 0900 hours, on the right deltoid area.
Review of the step-by-step guide for Lantus Solostar pen (undated) showed the following:
-the three possible injection sites were the abdomen, thighs and upper arms. These areas have more fat and fewer nerve endings; and
-when injecting in these areas, avoid the forearm. Only use the outer back area of the upper arm where there is a fatty tissue.
According to Taylor's Clinical Nursing Skills, seventh edition, showed the intramuscular injection sites are:
-Deltoid muscle of the arm (muscle forming the rounded contour of the human shoulder)
-Vastus lateralis muscle (located on the lateral side of the thigh
-Ventrogluteal muscle (located high on the buttocks, near the thigh)
According to https://www.healthline.com/health/diabetes/insulin-injection, insulin should be injected into the fatty tissue just below your skin. If you inject the insulin deeper into your muscle, your body will absorb it too quickly, it might not last as long, and the injection is usually more painful. This can lead to low blood glucose levels.
On 6/7/23 at 1112 hours, an interview and concurrent medical record review for Resident 23 was conducted with LVN 9. LVN 9 verified she gave the Lantus insulin injection on the deltoid area of Resident 23's right arm and she documented this in Resident 23's MAR. LVN 9 acknowledged the deltoid area was an intramuscular injection site, and not an injection site for medications to be given subcutaneously such as Lantus insulin medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to complete a laboratory test for o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to complete a laboratory test for one of 27 final sampled residents (Resident 2) as per the physician's order. This had the potential to result in the delay in evaluating the effectiveness of the medication and adjusting the dosage of the medication to meet Resident 2's needs.
Findings:
Medical record review for Resident 2 was initiated on 6/5/23. Resident 2 was admitted to the facility on [DATE].
Review of the Consultant Pharmacist's Medication Regimen Review dated 2/12/23, showed the Consultant Pharmacist's recommendation to arrange for CBC (a comprehensive blood test of the cells that make up blood), lipid panel (a blood panel which detects cholesterol levels), HgA1c (hemoglobin A1c, a blood test used to measure the average blood sugar levels over the past three months), LFT (liver function testing) for long-term Seroquel (an antipsychotic medication) use.
Review of the physician's order dated 3/14/23, showed an order to complete CBC, lipid panel, HgA1c, and LFT for long term use of Seroquel.
Review of Resident 2's laboratory test results dated 3/14/23, failed to show a HgA1c level was completed as per the physician's order.
On 6/12/23 at 1456 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and verified there was no HgA1c level completed for Resident 2.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observation, interview, facility document review, and P&P review, the facility failed to ensure the nutritional needs were met for two of 21 nonsampled residents (Residents 107 and 877) with ...
Read full inspector narrative →
Based on observation, interview, facility document review, and P&P review, the facility failed to ensure the nutritional needs were met for two of 21 nonsampled residents (Residents 107 and 877) with a vegetarian diet preference. This failure posed the threat of the nutritional needs of Residents 107 and 877 to not be met which could lead to medical complications. In addition, the facility failed to ensure the food preference was honored for one of 21 nonsampled residents (Resident 427). Resident 427 stated she disliked scrambled eggs; however, she was served scrambled eggs on her breakfast tray. This had the potential to negatively impact the resident's well-being.
Findings:
1. According to the California Health and Safety Code Section 1265.10: Effective 1/1/2019, skilled nursing facilities must make available wholesome, plant-based meals of such variety as to meet the needs of patients in accordance with their physicians' orders.
Review of the facility's P&P titled Vegetarian and Vegan Diet dated 2020 showed in part, the Academy of Nutrition and Dietetics recognizes that well planned vegetarian and vegan diets are consistent with good nutritional status .Provide at meals: Breakfast = 1 oz (ounce) protein equivalent, Lunch = 2-3 oz protein equivalent and Dinner = 2 oz protein equivalent. One ounce of protein is equivalent to six- seven gm (gram) of protein.
Review of the facility's document titled Cooks Spreadsheet showed the following:
* Week 1 Monday dated 6/5/23, showed for the lunch meal, two ounces Swedish meatballs with gravy for the entrée for regular and CCHO diets. The lunch meal entrée served for 6/5/23, was equivalent to 12-14 gm of protein.
* Week 1 Tuesday dated 6/6/23, showed for the lunch meal, three ounces Herb and Spice Roast Beef for regular and CCHO diets. The lunch meal entrée served was equivalent to 18-21 gm of protein.
Review of the facility's document titled Recipe: Peanut Butter and Jelly Sandwich undated showed one sandwich was equivalent to one ounce (seven gm) of protein.
Review of the facility's document titled Garden Burger, beef sub, patty meatless burger black ban cooked frozen vegetable undated showed one patty provided 11 gm (gram) of protein.
Review of the diet meal tickets for Residents 107 and 877 showed the following:
- For Resident 877, a CCHO (carbohydrate controlled) Regular diet, alerts: vegetarian diet.
- For Resident 107, a regular diet, alert: vegan.
During the lunch meal observation on 6/5/23 at 1220 hours, Resident 877's meal tray contained a peanut butter and jelly sandwich in place of the two ounces of Swedish meatballs served for regular CCHO diets, five to seven grams of protein less than the entrée served for regular and CCHO diets.
On 6/5/23 an interview was conducted with the DSS. The DSS stated the facility had a vegetarian menu in the diet manual, but it was not a separate diet on the cooks spreadsheet. When asked if the company providing the resident menus provided a menu for vegetarian diets, the DSS stated she was not sure. The DSS stated she asked the residents their preferences and worked around what vegetarian items were available from the facility's food vendor.
During the lunch meal tray line observation on 6/6/23 at 1127 hours, an interview was conducted with the DSS. The DSS stated vegetarian diets got a vegetarian black bean patty, mashed potatoes and spinach, which were seven to ten grams protein less than the entrée served for the regular and CCHO diets.
On 6/6/23 at 1332 hours, an interview was conducted with RD 1. RD 1 stated she approved the facility's menus. She stated she was not aware of a vegetarian menu for the facility, but the facility should have a vegetarian menu.
On 6/7/23, an interview was conducted with Resident 877. Resident 877 stated he preferred a vegetarian diet. Resident 877 stated the facility had not shown him a vegetarian menu or obtained vegetarian food preferences.
2. On 6/6/23 at 0745 hours, an observation and concurrent interview with Resident 427 was conducted.
Resident 427 was observed eating breakfast. Resident 427's breakfast plate contained a scrambled eggs and pancakes. Resident 427 was observed leaving her scrambled eggs on her plate and stated she ate the ice cold pancakes. Resident 427 stated she did not like the scrambled eggs since her childhood. Resident 427 further stated the facility staff was informed of her food preferences including the disliked of scrambled eggs.
Review of Resident 427's printed copy of the tray card showed Resident 427's diet order was a CCHO diet. The resident's food dislikes included the scrambled eggs.
On 6/6/23 at 0745 hours, a concurrent observation and interview was conducted with the Medical Records Director who was in the room of Resident 427. The Medical Records Director verified Resident 427 breakfast plate had scrambled eggs. The Medical Records Director reviewed the printed tray card and verified Resident 427's food dislikes included the scrambled eggs.
On 6/8/23 at 1601 hours, an interview and concurrent medical record review was conducted with the DSS. The DSS stated she was responsible on the nutritional assessment of the new residents including the residents' food preferences. The DSS was informed about Resident 427's findings of scrambled eggs on her breakfast plate and the scrambled eggs was her disliked food. The DSS reviewed the printed meal card and verified Resident 427 food preferences included the scrambled eggs as her disliked food. The DSS stated and acknowledged an error on updating the kitchen meal card and the Diet Report where the nurse to check the food cart. The DSS stated it should have been corrected to prevent an error on providing the resident food and follow their preferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on interview, medical record review, and facility document review, the facility failed to accurately determine whether one of 21 nonsampled residents (Resident 13) who was prescribed the antibio...
Read full inspector narrative →
Based on interview, medical record review, and facility document review, the facility failed to accurately determine whether one of 21 nonsampled residents (Resident 13) who was prescribed the antibiotics had met the McGeer's criteria. As a result, the facility failed to inform the resident's physicians that the residents did not meet McGeer's criteria for true infection and potentially inhibited the resident's physicians from discontinuing the unnecessary antibiotics. This had the potential to result in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria.
Findings:
According to the Centers for Disease Control and Prevention (CDC), antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms.
On 6/12/23 at 1510 hours, an interview, concurrent medical record review, and facility's document review was conducted with the IP. The IP stated she provided an oversight for the facility's antibiotic stewardship program. The IP stated for her surveillance process, she utilized McGeer's criteria to determine if a resident had a HAI or CAI, and if the resident did not meet McGeer's criteria, it would not be a true infection. The IP was asked what she would do if a resident on antibiotics did not meet McGeer's criteria. The IP stated she would give education to the practitioner; however, she had never done it before.
Review of the facility's document titled Surveillance Data Collection Form dated 3/8/23, for Resident 13, showed Resident 13 was started on doxycycline hyclate (an antibiotic) 100 mg tablet two times a day for UTI for seven days. The Surveillance Data Collection Form showed to identify if Resident 13 met and did not meet McGeer's criteria; however, the criteria section was not filled out. The IP stated Resident 13 would not meet McGeer's criteria and acknowledged the form was incomplete.
Review of Resident 13's medical record failed to show documented evidence the resident's physician was notified of Resident 13 not meeting the McGeer's criteria (thus potentially preventing the physicians from discontinuing the antibiotics for this resident). The IP verified the findings and acknowledged there was no documented evidence the resident's physician was notified.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal medications.
* The facility fa...
Read full inspector narrative →
Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal medications.
* The facility failed to ensure two expired oral inhaler medications were removed from Medication Cart A.
* The facility failed to ensure properly label an eye drop medication in Medication Carts A and B.
* The facility failed to ensure three opened insulin pens in Medication Carts A and B had an open date.
* The facility failed to ensure personal medications in Medication Cart A were removed and not used.
* The facility failed to ensure eight expired boxes of influenza vaccine were removed from the refrigerator in Medication Room A.
* The facility failed to ensure one opened insulin pen in the refrigerator in Medication Room A had an open date.
* The facility failed to ensure the IV E-kit in Medication Room A was replaced.
* The facility failed to ensure the orally administered medications were stored separate from externally used medications.
* The facility failed to ensure the medications for Resident 377 who had expired, and Residents 35 and 379 who were discharged from the facility had been removed from the current medication supply in the medication cart.
* The facility failed to properly label and store the lispro insulin pen (fast-acting insulin), inhalation solutions, and timolol Maleate eyedrop (used to treat glaucoma, a condition in which increased pressure in the eye can lead to gradual loss of vision) as per the manufacturer's instructions.
* The facility failed to ensure Resident 23's medications were not left unattended on the resident's bedside table, medications on top of the medication cart were not left unattended, and the IV medication cart was not left unlocked.
These failures had the potential to negatively impact the residents' well-being; had the potential for the medications to loss the stability and effectiveness; and had the potential for the residents, staff, and visitors to have access to the medications.
Findings:
Review of the facility's P&P titled Medication Labeling and Storage revised February 2023 showed the following:
- Multi-dose medications such as eye drops, liquid solutions, etc. when opened dated and discarded per manufacturer's package inserts/guidelines. If the package inserts/guidelines unavailable, pharmacy will be notified to provide information needed.
- The medication label includes, at a minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions.
- Multi-dose vials that have been opened or accessed (e.g., needles punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.
- Medications for external use, as well as hazardous drugs and biologicals, are clearly marked as such and are stored separately from other medications; and
- If the medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.
Under the Medication Storage section showed the following:
- The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items;
- Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medication and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others; and
- Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location.
Review of the facility's P&P titled Medications Brought to the Facility by the Resident/Family revised April 2007 showed the facility discourages the use of medications brought in from outside, and will inform the residents and families of that policy as well as applicable laws and regulations.
Review of the facility's P&P titled ICS: Emergency Pharmacy Service And Emergency Kits undated, showed when an emergency or state dose of medication is needed, the nurse unlocks the container and removes the required medication. After removing the medication, complete the emergency e-kit slip and re-seal the emergency supply. An entry is made in the emergency logbook containing all required information. A record of the name, dose of the drug administered, name of the patient, date, time of administration, and the signature of the person administrating the dose shall be recorded in the emergency logbook. If exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening.
1. On 6/8/23 at 1426 hours, an inspection of Medication Cart A was conducted with LVN 11. The following was observed:
- A fluticasone-umeclidinium vilant (Trelegy Ellipta) oral inhaler had expired on 6/5/23, and a fluticasone/salm (Advair Diskus) oral inhaler had expired on 5/11/23.
- A bottle of latanoprost (Xalantan) eye drops without a box nor label was found in the right upper drawer of the medicine cart.
- A bottle of latanoprost (Xalantan) eye drops was found in a container with a hospital labeling.
- Two insulin glargine (Lantus) and one insulin lispro (Humulin) pens were opened without an open date.
- A Ziploc bag contained multiple medication bottles, including panzoprazole 40 mg (a medication for heartburn and acid reflux), gabapentin 300 mg (a medication for nerve pain), Tylenol 325 mg (pain medication), methocarbamol 500 mg (a medication for muscle spasm or pain), and melatonin 3 mg (a supplement to aid sleep)
On 6/8/23 at 1433 hours, an interview and concurrent observation was conducted with LVN 11. LVN 11 verified the above findings. LVN 11 stated the insulin pens should have an open date after being opened and insulin pens were to be replaced within 28 days after the open date. LVN 11 further stated the expired medications should be removed from the medication cart. LVN 11 stated it was ok to give the resident's personal or home medications if the medication orders verified with the facility's physician were similar.
On 6/9/23 at 0901 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings identifed during Medication Cart A inspection. The DON stated the home medications were discouraged to be used while the residents were in the facility. The DON stated the medications not authorized from the pharmacy or expensive medications were used in special circumstances. However, the DON further stated similar home medications that can be supplied from the pharmacy should not be used in the facility.
2. On 6/9/23 at 0801 hours, an inspection of Medication Room A was conducted with RN 2. The following was observed:
- An IV E-kit was observed with a yellow zip tie which meant it was opened. However, the IV E-kit did not have a paper slip inside the E-kit to show what supplies were taken out nor what day the E-kit was opened.
- Eight boxes of Influenza Vaccine Afluria Quadrivalent inside the medication refrigerator had expired on 5/30/23.
- One Ozempic injectable pen inside the medication refrigerator was opened without an open date.
On 6/9/23 at 0818 hours, RN 2 verified the above findings.
On 6/9/23 at 1440 hours, the DON was informed and acknowledged the above findings.
3. On 6/8/23 at 1427 hours, an inspection of Medication Cart B, concurrent interview, and medical record review was conducted with LVN 4. The following was observed:
a. The following medications were observed for Resident 377:
- a bottle of active liquid protein (protein supplement);
- a bottle of enema laxative (a saline laxative given as an injection of fluid into the lower bowel by way of the rectum to prove relief from constipation);
- a bottle of biotin (vitamin B supplement); and
- a bottle of calcium (supplement).
Review of Resident 377's medical record showed a physician's order dated 6/5/23, may pick-up remains by the mortuary.
b. A bottle of calcifediol capsule (vitamin D3 supplement) was observed for Resident 35.
Review of Resident 35's medical record showed a physician's order dated 5/24/23, to transfer Resident 35 to the acute care hospital.
c. Boxes of nicotine transdermal system patch (used to help people stop smoking cigarettes) and Stiolto Respimat (medication used to prevent airflow obstruction) inhaler were observed for Resident 379.
Review of Resident 379's medical record showed a physician's order dated 6/6/23, to transfer Resident 379 to the acute care hospital.
d. A lispro insulin pen (to control high blood sugar) was observed open with no open date.
e. An opened timolol maleate eyedrop (lower the pressure in the eye) was observed open with no open date.
Review of the manufacturer's guideline for Timolol eyedrops dated 8/25/22, showed to use the timolol eye drops within the expiry date shown on the bottle and within four weeks of opening.
f. Opened foil packets containing units of budesonide inhalation (used to treat asthma), albuterol inhalation (used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases such as asthma and chronic obstructive pulmonary disease or COPD; a group of diseases that affect the lungs and airways), and ipratropium-albuterol inhalation (used to treat COPD) with no open dates.
Review of the medication packet insert for budesonide inhalation suspensions (undated) showed when an envelope has been opened, the shelf life of the unused ampules is two weeks.
Review of the medication instructions on the foil packet for ipratropium bromide and albuterol sulfate inhalation solution showed once removed from the foil pouch, the individual vials should be used within two weeks.
g. Medications for external use were stored with the other medications, including breathing treatment and oral medications inside the 4th drawer of medication cart. For example:
- a compartment was observed with a tube of topical Diclofenac Sodium (used to treat pain and other symptoms of arthritis of the joints), an enoxaparin (used to prevent blood clots) injection, and boxes of inhalation solutions stored with a carton of Jevity 1.5 ( calorically dense, fiber-fortified therapeutic nutrition), a bottle of polyethylene glycol (used to treat occasional constipation. ), a bottle of alendronate sodium (used to treat osteoporosis, thinning of the bone), a bottle of ondasentron (used to prevent nausea and vomiting ) and a bottle of methylprednisolone (relieves inflammation and is used to treat certain forms of arthritis; skin, blood, kidney, eye, thyroid, and intestinal disorders severe allergies; and asthma)
- another compartment was observed with a bottle of laxative enema, Trelegy Ellipta inhaler (used long term to treat COPD), and bottles of liquid protein, biotin, and calcium.
-another compartment was observed with albuterol and Stiolto Respimat (used to treat COPD) inhalers, budesonide inhalation solutions, and a bottle of Robafen (expectorant).
-another compartment was observed with a tube of topical Diclofenac Sodium, bottles of Glycolax (used to treat occasional constipation), nystatin oral suspension (fiber supplement), docu-liquid (used to treat occasional constipation), and vitamin C (supplement).
h. A bottle of vitamin C was observed with brown sticky substance on the bottle causing a brownish stain at the bottom of the medication cart drawer and other medication bottles.
LVN 4 verified the above findings.
4. On 6/8/23 at 1535 hours, during the Medication Cart B inspection with LVN 4. LVN 4 was observed placing several medications on top of the medication cart. LVN 4 was observed asking LVN 10 to supervise the medications while LVN 4 looked for the glucometer calibration log, and LVN 10 agreed. LVN 10 was observed walking away from the medication cart and looking at the computer screen in the nursing station. The medications on top of the medication cart were left unattended. Staff were observed passing by the medication cart.
On 6/8/23 at 1537 hours, there were no licensed staff observed in the nursing station, and the medications on top of the medication cart were left unattended. Staff and residents were observed passing by the medication cart.
On 6/8/23 at 1538 hours, LVN 10 went back to the nursing station, sat on the chair, and observed looking at the computer screen with her back turned away from the medication cart. The medications on top of the medication cart were left unattended. Staff and visitors were observed passing by the medication cart.
5. On 6/7/23 at 0806 hours, a medication administration observation for Resident 23 was conducted with LVN 9. The following was observed:
- At 0825 hours, LVN 9 prepared Resident 23's medications which included a medication cup containing seven tablets, one regular cup containing laxative medication mixed with water, four eyedrops, and one insulin injection. LVN 9 was observed placing the tray with the medications on the resident's bedside table, went to the resident's bathroom, and washed her hands. The medications were left on the bedside table unattended, out of LVN 9's reach and sight.
- During the observation from 0830 to 0845 hours, LVN 9 was observed administering three eye drops, oral medications, checking the blood sugar level, and administering the insulin. However, after each medication administration and blood sugar checking, LVN 9 was observed leaving the remaining medications unattended on the bedside table to wash her hand in the resident's bathroom. The unattended medications were out of LVN 9's reach and sight each time.
On 6/7/23 at 0900 hours, LVN 9 verified the above findings.
6. On 6/9/23 at 0753 hours, the IV medication cart was observed parked in front of Station A facing the hallway. The IV medication cart was observed unlocked. Staff were observed passing by the hallway.
On 6/9/23 at 0755 hours, RN 2 was called for IV medication cart inspection. RN 2 verified the IV medication cart was unlocked. RN 2 acknowledged the IV medication cart contained IV antibiotic medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to show their Quality Assessment and Assurance (QA&A) plan of correction. There was no evidence of documentation to show the facility had develo...
Read full inspector narrative →
Based on observation and interview, the facility failed to show their Quality Assessment and Assurance (QA&A) plan of correction. There was no evidence of documentation to show the facility had developed a plan of correction for the repeated deficient practices cited at F558, F689, F694, F758, F759, F761, F806, F812, and F880 from the last recertification survey completed on 4/21/21. This had the potential to negatively affect the quality of care for all the residents in the facility.
Findings:
During the recertification survey from 6/5/23-6/13/23, the following deficient practices: F558, F689, F694, F758, F759, F761, F806, F812, and F880 were identified, which were the repeated deficient practices cited from the last recertification survey completed on 4/21/21.
On 6/13/23 at 1518 hours, an interview was conducted with the Administrator. The Administrator was asked to show documentation of the facility's QA&A plan of correction developed to prevent the deficient practices cited at F558, F689, F694, F758, F759, F761, F806, F812, and F880 from the last recertification survey to reoccur. The Administrator was unable to provide any documented evidence the QA&A had developed and implemented the appropriate plan of action to correct those identified deficiencies. The Administrator further stated they could not find the binder for this QA&A plan of action.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of the facility's P&P titled Surveillance for Infections revised 9/2017 showed the IP will conduct ongoing surveillanc...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of the facility's P&P titled Surveillance for Infections revised 9/2017 showed the IP will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) by using the current suggested criteria for Healthcare-Associated Infections to determine if the resident has a Healthcare-Associated Infection.
Review of the facility's Infection Control Monthly Summary from March 2023 showed there were 29 residents with HAIs, 27 residents with CAIs, and 56 residents with prescribed antibiotics.
On 6/12/23 at 1510 hours, an interview, medical record review, and facility document review was conducted with the IP Specialist. The IP Specialist was asked how she had conducted surveillance of the residents' infections at the facility. The IP Specialist stated if the resident developed the infection in the facility within three days, it would be classified as a CAI; and if the resident developed the infection in the facility after three days, it would be classified as an HAI.
The IP was asked what criteria she used to determine if a resident had an infection. The IP stated the facility utilized McGeer's criteria to determine if a resident had HAI or CAI. The IP stated if the resident did not meet McGeer's criteria, it would not be a true infection.
The IP then reviewed the facility document titled Surveillance Data Collection Form dated 3/8/23, for Resident 13. The Surveillance Data Collection Form showed Resident 13 was started on doxycycline hyclate (antibiotic) 100 mg tablet two times a day for UTI for seven days. The Surveillance Data Collection Form also showed Resident 13's infection did not meet McGeer's criteria for true infection, however, the McGeer's criteria section was not filled out. The IP acknowledged the form was incomplete.
Review of Resident 13's urine culture laboratory test results showed a urine culture result of 80,000 colonies/ml of gram of multiple organisms. The IP Specialist stated to meet criteria, the urine culture needed to be over 100,000 colonies/ml. After the IP Specialist reviewed Resident 13's medical record, the IP Specialist stated Resident 13 did not have any symptoms so it did not meet McGeer's criteria.
Cross reference to F881.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment; and prevent the transmission of diseases and infections to all residents.
* The facility failed to ensure the infection control practices were implemented in the facility's laundry room.
* The facility failed to ensure the staff performed hand washing when passing breakfast trays among residents.
* The facility failed to follow the physician's order for isolation precautions for Resident 47 who had shingles (a painful, usually itchy, rash that develops on one side of the face or body, and consists of blisters that typically scab over in seven to ten days and fully clear up within two to four weeks).
* The facility failed to implement the contact/droplet precautions when entering the rooms of residents who tested positive for COVID-19.
* The facility failed to implement the enhanced standard precaution for one nonsampled resident (Resident 114) as per the physician's order.
* The facility failed to ensure the pads used for the bed side rails for two of 27 final sampled residents (Residents 25 and 65) were not porous, torn, and frayed.
* The facility failed to ensure the Surveillance Data Collection Form was complete and accurate to determine whether the resident's infection meet the McGeer's criteria for true infection.
These failures posed the risk for transmission of disease-causing microorganisms.
Findings:
1. Review of the facility's P&P titled Departmental Environmental services-Laundry and Linen revised on January 2014 showed all soiled linen must be placed directly into a covered laundry hamper
On 6/8/23 at 0830 hours, an inspection of laundry room was conducted with Maintenance Director. The following was identified:
- Personal belongings were observed in the clean linen area, including a black cap, face shield, white binder, blender bottle, staff food, staff cellphone and charger, and black radio.
- Four soiled linen carts were observed; however, one of the soiled linen carts with green blankets was uncovered.
- Three trash bins were observed; however, one of the trash bins with soiled isolation gowns was uncovered.
The above findings were verified by the Maintenance Director.
On 6/12/2023 at 1607 hours, an interview was conducted with the IP Specialist. The IP Specialist stated the staff's personal belongings should not be stored in the clean linen area, and the trash bins and soiled linen carts should be covered.
2. On 6/6/23 at 0708 hours, the Medical Records Assistant was observed passing breakfast trays to Rooms E and F. After placing the breakfast trays on the table, removing the cover, and handling the silverware to the resident in Room E, the Medical Records Assistant did not perform hand hygiene and proceeded to Room F to pass the breakfast tray. The Medical Records Assistant verified she did not perform hand hygiene in between passing of trays and handling silverwares to the residents in Rooms E and F.
4. Review of the facility's document dated 6/6/23, showed Rooms A and B had the residents who were tested positive for COVID-19.
a. On 6/6/23 at 0708 hours, Room A was observed with a contact/droplet precautions signage posted on the door and a metal compartment hanging at the door with yellow gown, gloves, N95 masks, and bleach wipes container.
Review of the facility's signage for contact/droplet precautions showed the following:
- Everyone must clean their hands, including before entering and when leaving the room.
- Everyone must put on gown before room entry and discard gown before room exit.
- Everyone must put on an N95 mask before entry.
- Apply face shield or goggles.
- Clean hands again, put on gloves before room entry, and discard gloves before room exit.
CNA 2 was observed entering Room A and closed the door. CNA 2 was wearing a yellow gown, face shield, gloves, and surgical mask. However, CNA 2 did not wear an N95 mask prior to entering Room A's room as per the facility's signage for contact/droplet precautions.
On 6/6/23 at 0723 hours, an interview was conducted with CNA 2. CNA 2 verified the above findings. CNA 2 stated she responded to a call light to assist a resident in Room A. CNA 2 confirmed there was a contact/droplet precautions sign posted on Room A's door and was supposed to wear an N95 mask for the rooms with the residents who were tested positive for COVID-19. CNA 2 further stated she forgot to change her mask to an N95 mask before entering Room A.
On 6/6/23 at 0731 hours, an interview was conducted with the IP Specialist. The IP Specialist stated for rooms with contact/droplet precautions, all staff must perform hand hygiene, wear a gown, N95 mask, face shield, and gloves. The IP was informed and verified the above finding.
b. On 6/6/23 at 0838 hours, Room B was observed with a contact/droplet precautions signage posted on the door and a three-tier cart with yellow gown, gloves, N95 masks, and bleach wipes container. CNA 3 was observed entering Room B wearing a yellow gown, face shield, gloves, and surgical mask.
On 6/6/23 at 0841 hours, CNA 3 was observed exiting Room B holding a breakfast tray, placing the tray on the meal cart, and performing hand hygiene.
On 6/6/23 at 0844 hours, an interview was conducted with CNA 3. CNA 3 was informed verified the above finding. CNA 3 stated he was supposed to wear an N95 mask for Room B and did not change his mask.
On 6/6/23 at 0848 hours, an interview was conducted with LVN 2. LVN 2 confirmed Room B was on contact/droplet precautions due to the residents in the room were tested positive for COVID-19.
5. Review of the facility's P&P titled Isolation- Initiating Transmission-Based Precautions revised August 2019 showed when Transmission-Based Precautions are implemented, the IP Specialist or designee determines the appropriate notifications on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions; and ensures that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment.
Medical record review for Resident 114 was initiated on 6/7/23. Resident 114 was readmitted to the facility on [DATE].
Review of Resident 114's laboratory result for urine culture dated 6/1/23, showed an abnormal result of greater than 100,000 colonies/ml of vancomycin resistant enterococcus faecium (bacteria).
Review Resident 114's Order Summary Report for June 2023, showed a physician's order dated 6/1/23, to implement enhanced standard precaution related to infections. Handwashing/hand sanitizing, gown, and gloves were required.
However, on 6/7/23 at 0856 hours, Resident 114's room was observed not having a signage for enhanced standard precautions and a cart with PPEs needed for enhanced standard precautions outside the room for staff to use.
On 6/7/23 at 0856 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the above finding and stated the order for Resident 114's enhanced standard precautions was active. LVN 1 further stated she had to ask the IP Specialist what the purpose was for the enhanced standard precaution.
On 6/7/23 at 1139 hours, an observation and concurrent interview was conducted with the IP Specialist. The IP Specialist verified the above finding. The IP Specialist stated Resident 114 should be on enhanced standard precautions because the urine culture results showed Resident 114 had vancomycin resistant enterococcus faecium (bacteria). The IP stated she would place a signage for enhanced standard precaution and a PPE cart.
Cross reference to F656, example #1.
6.a. On 6/6/23 at 0921 hours, and 6/7/23 at 0906 hours, Resident 25 was observed in bed with bilateral half padded side rails. However, the side rail pads were observed with porous tears, holes, and ripped.
On 6/7/23 at 1355 hours, an observation of Resident 25's padded side rails and concurrent interview was conducted with the Maintenance Director. The Maintenance Director verified the above finding. The Maintenance Director verified the padding could not be cleaned so they needed to be replaced right away.
b. On 6/5/23 at 0931, Resident 65 was observed in bed with with a black colored porous foam padded bilateral half side rails elevated.
On 6/7/23 at 1456 hours, an observation and interview for Resident 65 was conducted with the Maintenance Director. The Maintenance Director verified Resident 65's side rails were with black foam pad. The Maintenance Director was asked if the materials use for padding the side rails were made with porous materials, the Maintenance Director verified the padded materials used were porous. The Maintenance Director was asked if the padding material can be totally disinfected when cleaned by bleach. The Maintenance Director acknowledged the porous foam pad can not be 100% disinfected.
3. Review of the facility's P&P titled Isolation - Categories of Transmission-Based Precautions revised 9/2022 showed when a resident is placed on transmission-based precaution, appropriate notification is posted on the entrance door of the room and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC precautions, instructions for the use of PPE, and/or instructions to see a nurse before entering the room. The signage and notifications must comply with the resident's right to confidentiality or privacy.
Review of the CDC Type and Duration of Precautions Recommended for Selected Infections and Conditions updated 9/2018 showed the following:
- For herpes zoster (varicella-zoster or shingles) infection that is disseminated in any patient, or localized in immunocompromised patient until disseminated infection ruled out, the type of precautions to be followed are airborne, contact, and standard precautions, and the duration of the illness is the duration of the precaution
- For herpes zoster infection that is localized in patient with intact immune system with lesions that can be contained or covered, the type of precaution is standard, and the duration of the precaution is until lesions are dry and crusted.
On 6/7/23 at 0844 hours, Resident 47 was observed in bed. There was no isolation precaution signage observed on the door.
Medical record review for Resident 47 was initiated on 6/5/23. Resident was initially admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 47's Order Summary Report showed the following physician's order dated 5/28/23:
- To implement strict contact isolation precaution due to shingles rash to left scalp
- To administer Valtrex (antiviral, used to treat herpes virus infection) 1 gram three times a day for shingles rash to the left side of scalp for seven days with an end date of 6/4/23.
Review of Resident 47's plan of care showed a care plan problem to address Resident 47's recurring shingles rash to the left side of scalp.
However, during the above observation, the contact isolation precaution was not implemented.
Further review of Resident 47's medical record showed no documented evidence the contact isolation precaution was discontinued.
On 6/7/23 at 1352 hours, an interview and concurrent medical record review for Resident 47 was conducted with LVN 9. LVN 9 verified there was no isolation precaution observed for Resident 47. LVN 9 stated Resident 47 had been on isolation precaution but it was discontinued on 6/6/23. When asked who discontinued the isolation precaution, LVN 9 stated she did not know. LVN 9 further stated she came to work on 6/6/23, and the isolation precaution had been discontinued.
On 6/7/23 at 1405 hours, an interview and concurrent medical record review for Resident 47 was conducted with the IP Specialist. When asked about the isolation precaution order for Resident 47, the IP Specialist verified there was an active physician's order for isolation precaution for shingles for Resident 47. The IP Specialist stated Resident 47's shingles had crusted over so she informed the physician, and the isolation precaution was discontinued; however, the IP Specialist was unable to provide documented evidence the physician was informed regarding Resident 47's shingles lesion and discontinued the contact isolation precaution order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen and patient care equipment was maintained.
* The ice machine manufacturer'...
Read full inspector narrative →
Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen and patient care equipment was maintained.
* The ice machine manufacturer's guidelines for cleaning and sanitizing were not followed and the ice machine did not have an air gap.
* The walk-in freezer floor located in the kitchen was not leveled.
* The facility failed to ensure the glucometers (a device which measures the amount of sugar in the blood) currently used and stored in the medication carts were properly calibrated. The facility failed to ensure the glucometer monitoring log was completed and the quality control showed the serial numbers of the glucometer calibrated. In addition, the facility failed to ensure the control solutions used to calibrate the glucometer machine for Station 1 were not expired. This posed the risk for inaccurate blood glucose test results and inappropriate treatments, which posed the risk of inaccurate blood glucose readings used to determine the residents' insulin doses.
These failures posed the risk of equipment to not function properly, which could negatively impact the residents' well-being.
Findings:
1. Review of the facility's P&P titled Ice Machine Cleaning Procedures undated showed, Procedure 3. Clean inside of ice machine with a sanitizing agent per the manufacturer's instructions.
Review of the ice machine Cleaning System Instructions located on the inside cover of the ice machine showed in part, Use only [Manitowoc] approved ice machine cleaner and sanitizer
According to the USDA Food Code 2022 5-402.11 Backflow Prevention, (A) .a direct connection may not exist between the SEWAGE system and a drain originating from equipment in which food, portable equipment, or utensils are placed.
On 6/5/23 at 1048 hours, an observation of the ice machine and concurrent interview was conducted with the Maintenance Director. The ice machine cleaning and sanitizing process was reviewed with the Maintenance Director. The Maintenance Director stated he cleaned the ice machine monthly, removed the internal components, and cleaned the internal components every six months. The Maintenance Director showed the cleaning and sanitizing agents used to clean and sanitize the ice machine. The Maintenance Director confirmed the cleaning and sanitizing agents were not the brand as specified in the ice machine Cleaning System Instructions. The Maintenance Director was asked to show the air gap of the ice machine. The Maintenance Director showed the drainpipe of the ice machine which was plumbed directly into the wall which was connected to the shower drain in the adjacent shower room.
2. Review of the facility's P&P titled Sanitation dated 2023 showed in part, 7. The FNS (food and nutrition services) Director (and/or cook in their absence) will report any equipment needing repair to the maintenance man.
During the initial tour of the kitchen on 6/5/23 at 800 hours, an observation of the walk-in freezer floor and concurrent interview was conducted with [NAME] 1. The walk-in freezer floor was not level and had a raised section creating a gap approximately three feet in length. [NAME] 1 confirmed the findings.
On 6/5/23 at 1005 hours, an observation of the walk-in freezer floor and concurrent interview was conducted with the DSS. The DSS confirmed the floor needed repair. The DSS stated if the kitchen equipment needed repair, there was a maintenance log for the kitchen, but she just verbally told the Maintenance Director if there was a problem, the log was not utilized.
On 6/5/23 at 1040 hours, an interview was conducted with the Maintenance Director. The kitchen staff should record the maintenance problem in the maintenance log book located at the nursing station or they could just call him. The Maintenance Director stated he was aware of the walk-in freezer floor and stated the repair was a long process. The Maintenance Director stated he gave quotes for the repair to the previous Administrator.
On 6/5/23 at 1506 hours, an interview was conducted the Regional Consultant for Operations. The Regional Consultant for Operations stated he would try to find documentation on the walk-in freezer floor. By the exit date of the survey on 6/13/23, the Regional Consultant for Operations had not produced any documentation of quotes on the walk-in freezer floor.
3. Review of the Assure Platinum Blood Glucose Monitoring System Instruction Manual, under Quality Checks, showed to use Assure Dose Control Solutions to check if the meter and test strips are working correctly as a system, and to check if the test was correct. A control solution test is performed when a new bottle of test strips is opened. The control solution is used within 90 days of first opening. When a control solution test is performed, make sure the result is within the acceptable range printed on the test strip bottle. Do not use the system if the control solution result is out of range.
On 6/8/23 at 1548 hours, an inspection of the glucometer on Station 1 was conducted with LVN 4. A glucometer machine was observed in the medication cart. The control solution was opened and dated 3/2/23. When asked how long an opened control solution would be good for, LVN 4 did not answer. LVN 4 was informed an opened test control solution was good for 90 days (as per the glucometer manual). LVN 9 verified the control solution was expired. When asked how often the control test was performed, LVN 4 stated the control test was performed every night during the 2300 to 0700 hours shift. LVN 4 showed the calibration logs in a binder, and another glucometer machine with another brand was observed inside the binder.
a. Review of the facility's document titled Blood Glucose Monitoring System: Quality Control for Unit 1 showed the following:
- For April 2023, the glucometer calibration was not performed on 4/29 and 4/30/23.
- For May 2023, the glucometer calibration was not performed on 5/3, 5/6, 5/7, 5/8, 5/14, 5/15, 5/19, 5/20, 5/21, 5/25, 5/26, 5/27, 5/28, and 5/31/23; and the document did not show the brand name and the serial number of the glucometer.
- For June 2023, the glucometer calibration was performed on 6/1 to 6/7/23, but did not show the brand name and serial number of the glucometer.
b. Review of the facility's document titled Blood Glucose Monitoring System: Quality Control for Unit 2 showed the following:
- For April 2023, the glucometer calibration was not performed on 4/29 and 4/30/23.
- For May 2023, the glucometer calibration was not performed on 5/3, 5/14, 5/15, 5/19, 5/20. 5/21, 5/24, 5/25, 5/26, 5/27, and 5/28/23, 5/27, 5/28 and 5/3123; and the document did not show the brand name and serial number of the glucometer.
- For June 2023, the glucometer calibration was not performed on 6/6 and 6/7/23; and the document did not show the brand name and the serial number of the glucometer.
c. Review of the facility's document titled Blood Glucose Monitoring System: Quality Control for Unit 3 showed the following:
- For April 2023, the glucometer calibration was not performed on 4/29 and 4/30/23.
- For May 2023, the glucometer calibration was not performed on 5/14, 5/15, 5/19, 5/20. 5/21, 5/25, 5/26, 5/27, 5/28, and 5/3123; and the document did not show the brand name and serial number of the glucometer.
- For June 2023, the glucometer calibration was not performed on 6/6 and 6/7/23, and the document did not show the brand name and serial number of the glucometer. The document, under the column Station/ Shift, also showed IV (or Station 4).
d. Review of the facility's document titled Blood Glucose Monitoring System: Quality Control for Unit 3 showed the following:
- For April 2023, the glucometer calibration was not performed on 4/29 and 4/30/23.
- For May 2023, the glucometer calibration was not performed on 5/14, 5/15, 5/19, 5/20. 5/21, 5/25, 5/26, 5/27, 5/28, and 5/31/23; and the document did not show the brand name and serial number of the glucometer.
- For June 2023, the glucometer calibration was not performed on 6/6 and 6/7/23, and the document did not show the brand name and serial number of the glucometer. The document, under the column Station/ Shift, also showed III (or Station 3).
e. Review of the facility's document titled Assure Platinum Blood Glucose Monitoring System: Quality Control Record for May 2023 showed the following:
- For Unit 1, the glucometer calibration was not performed on 5/1, 5/2, 5/6 to 5/14, and 5/19 to 5/31/23.
- For Unit 2, the glucometer calibration was not performed from 5/1 to 5/17/23, and 5/19 to 5/31/23.
- For Unit 3, the glucometer calibration was not performed from 5/1 to 5/17/23, and 5/19 to 5/31/23.
- There was no glucometer calibration performed for the glucometer in Unit 4.
LVN 4 verified the above findings. LVN 4 stated the facility used the Blood Glucose Monitoring System: Quality Control form to document the glucometer calibration log. LVN 4 did not know why there were other forms used to document the glucometer calibation log for each station.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 6/5/23 at 1500 hours and 6/12/23 at 0845 hours, Resident 72 was observed in bed with the left side of the bed against the ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 6/5/23 at 1500 hours and 6/12/23 at 0845 hours, Resident 72 was observed in bed with the left side of the bed against the wall. The side rails were elevated on both sides of the bed, a floor mat was on the right side of the bed, and a bed alarm was hanging from the right side rail.
Medical record review for Resident 72 was initiated on 6/7/23. Resident 72 was admitted to the facility on [DATE].
Review of Resident 72's MDS dated [DATE], showed Resident 72 had severe cognitive impairment and required extensive assistance from two staff for bed mobility.
Review of the Order Summary Report as of 6/8/23, showed a physician's order dated 11/30/22, to have both top half side rails up times as an aid to bed mobility/turning and repositioning.
7. On 6/5/23 at 1103 hours and 6/7/23 at 1058 hours, Resident 86 was observed in bed with bilateral half side rails elevated.
Medical record review for Resident 86 was initiated on 6/7/23. Resident 86 was admitted to the facility on [DATE].
Review of Resident 86's MDS dated [DATE], showed Resident 86 required extensive assistance of two staff for bed mobility.
Review of Resident 86's Order Summary Report for June 2023 showed a physician's order for both half side rails up as an aid to bed mobility/turning and repositioning.
On 6/8/23 at 1052 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Director stated upon a resident's admission, he measured the bed. The Maintenance Director further stated he performed bed inspection for each bed in the facility monthly. When asked about the bed inspection process, the Maintenance Supervisor stated the facility had a standard mattress to which he already knew the measurements; however, if there was a new type of mattress ordered, he would then measure the new mattress. When asked if he would measure low air loss mattresses, the Maintenance Supervisor answered no, he would only measure regular mattresses. When asked about the different zones of possible entrapment, the Maintenance Supervisor stated he used the bed system measurement device to measure the distance from side rails to mattress, and from mattress to headboard, and from mattress to footboard. When asked to provide bed inspection log and documentation of the measurements of the bed dimensions with the possible areas of entrapment, the Maintenance Supervisor stated he did not use any bed inspection logs.
On 6/8/23 at 1635 hours, an interview was conducted with the DON. When asked about the bed inspection, the DON stated she was not familiar with the bed inspection process in the facility.
On 6/13/23 at 0944 hours, an interview was conducted with the Administrator. The Administrator was asked the process of the bed inspection, he stated he did not know the whole bed inspection process, and there was no bed inspection binder or log.
Based on observation, interview, and facility P&P review, the facility failed to ensure the regular inspection of all the bed frames, mattresses, and side rails was conducted as part of the regular maintenance program to identify areas of possible entrapment rails. This failure had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death.
Findings:
According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are:
- Zone 1: within the rail;
- Zone 2: under the rail, between the rail supports or next to a single rail support;
- Zone 3: between the rail and the mattress;
- Zone 4: under the rail, at the ends of the rail;
- Zone 5: between split bed rails;
- Zone 6: between the end of the rail and the side edge of the head or foot board; and
- Zone 7: between the head or foot board and the mattress end.
Review of the facility's P&P titled Bed Safety and Bed Rails revised August 2022 showed the following:
- Bed frames, mattresses and bed rails are checked for compatibility and size prior to use.
- Bed dimensions are appropriate for the resident's size.
- Regardless of the mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gap in the bed system is within the safety dimensions established by the FDA.
- Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks.
- The maintenance department provides a copy of inspections to the administrator and report results to the QAPI committee for appropriate actions. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee.
- Bed rails are properly installed and used according to the manufacturer's instructions, specifications, and other pertinent safety guidance to ensure proper fit (e.g. avoid bowing, ensure proper distance from the headboard and footboard, etc.).
However, a concurrent observation, medical record review for Residents 21, 25, 65, 72, 115, and 727, and facility document review showed the resident beds were not inspected for possible entrapment. For example:
1. On 6/6/23 at 0921 hours, and 6/7/23 at 0906 hours, Resident 25 was observed in bed with bilateral half padded side rails elevated.
Medical record review for Resident 25 was initiated on 6/6/23. Resident 25 was readmitted to the facility on [DATE].
Review of Resident 25's MDS dated [DATE], showed Resident 25 had severe cognitive impairment and required extensive assistance of two staff for bed mobility.
Review of Resident 25's Order Summary Report dated June 2023 showed a physician's order dated 4/26/23, for both top half padded side rails up in bed for seizure disorder.
Review of Resident 25's admission Side/Bed Rail Evaluation/Consent dated 4/6/19, showed the side rails were use for bed mobility and assist with transfer.
2. On 6/6/23 at 1045 hours, Resident 115 was observed in bed with left half side rail elevated with a hanging metal basket compartment for Resident 115's wound vac machine and right half side rail down.
Medical record review for Resident 115 was initiated on 6/6/23. Resident 115 was admitted in the facility on 5/23/23.
Review of Resident 115's MDS dated [DATE], showed Resident 115 was cognitively intact and required limited assistance of one staff for bed mobility.
Review of Resident 115's Order Summary Report dated June 2023 showed a physician's order dated 5/23/23, for both top half side rails up as an aid to bed mobility, turning, and repositioning.
Review of Resident 115's Nursing-Bed Rail Observation/assessment dated [DATE], showed the use for side rails was for safety, security, and positioning enabler.
3. On 6/6/23 at 1003 hours and 6/7/23 at 0904 hours, Resident 727 was observed in bed with bilateral half side rails elevated.
Medical record review for Resident 727 was initiated on 6/6/23. Resident 727 was admitted to the facility on [DATE].
Review of Resident 727's H&P examination dated 3/18/23, showed Resident 727 had the capacity to understand and make decisions
Review of Resident 727's MDS dated [DATE], showed Resident 727 required extensive assistance of one staff for bed mobility.
Review of Resident 727's Order Summary Report for the month of June 2023 showed a physician's order dated 3/18/23, for both top half side rails up as an aid to bed mobility, turning, and repositioning.
Review of Resident 727's Nursing- Bed Rail Observation/assessment dated [DATE], showed the use for side rails was for safety, security, and positioning enabler.
6. On 6/5/23 at 0931 hours, and 6/7/23 at 0902 hours, Resident 65 was observed in bed with bilateral half side rails elevated.
Medical record review for Resident 65 was initiated on 6/6/23. Resident 65 was admitted to the facility on [DATE].
Review of Resident 65's MDS dated [DATE], showed Resident 65 required extensive assistance of one staff for bed mobility.
Review of Resident 65's Order Summary Report forJune 2023 showed a physician's order dated 4/18/22, for padded top half side rails up to both side of the bed for safety/ mobility due to seizure disorder.
5. On 6/6/23 at 0911 hours, 6/7/23 at 0930 and 1442 hours, and 6/8/23 at 1008 hours, Resident 21 was observed lying in bed with bilateral side rails elevated.
Medical record review for Resident 21 was initiated on 6/5/23. Resident 21 was admitted to the facility on [DATE].
Review of Resident 21's MDS dated 419/23, showed Resident 21 had severe cognitive impairment, and required extensive assistance from one staff for bed mobility.
Review of Resident 21's Order Summary Report showed a physician's order dated 4/13/23, for both top half side rails up as an aid to bed mobility, turning and repositioning.
Review of Resident 21's Nursing - Bed Rail Observation/ assessment dated [DATE], showed the side rails were considered for positioning enabler and would assist Resident 21 with bed mobility and transfer. Under the section for Evaluation of Entrapment Risk, the assessment form showed there were no gaps on the right side, left side, headboard, and footboard. Under the section for Evaluation of Resident's Size and Weight, the assessment form showed, yes was marked to answer if the bed dimensions were appropriate for the resident's size and weight, based on visual inspection of the resident in bed, and the resident's verbalized comfort level.
However, further review of the medical record did not show the bed dimensions and seven zones of entrapments were measured based on the change of bed or mattress or resident's size and weight.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, facility document review, and P&P review, the facility failed to ensure the professional standards for food safety and sanitation guidelines were followed when:
1. Pas...
Read full inspector narrative →
Based on observation, interview, facility document review, and P&P review, the facility failed to ensure the professional standards for food safety and sanitation guidelines were followed when:
1. Pasteurized eggs were not used to serve under cooked eggs.
2. Time Temperature Control for Safety Foods (TCS) (food that require time and temperature controls to limit the growth of illness causing bacteria) were not handled safely.
3. Expired food was not discarded.
4. Food was not stored properly.
5. Food was not dated.
6. Hair restraints were not worn appropriately.
7. Food contact surfaces were worn and no longer cleanable.
8. Kitchen equipment was not clean.
These failures had the potential to cause food borne illnesses in a medically vulnerable population of 131 who received food prepared in the kitchen.
Findings:
Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility on 6/5/23, showed 131 of 131 residents in the facility received food prepared in the kitchen.
1. Review of the facility's P&P titled Procedure For Refrigerated Storage dated 2018 showed the raw eggs shall be obtained pasteurized.
During the initial tour of the kitchen with [NAME] 1 on 6/5/23 at 0821 hours, two cases of eggs were observed in the reach-in refrigerator. The eggs did not have a label indicating the eggs were pasteurized.
On 6/6/23 at 0617 hours, a concurrent observation and interview was conducted with the DSS in the kitchen. The DSS assisted the kitchen staff with the residents' breakfast meal preparation. The DSS stated certain residents got fried eggs every day with the preference for a soft and runny (somewhat liquid, not firm) egg yolk. The DSS was observed making two fried eggs on the grill for Resident 68's breakfast meal tray, and the meal ticket showed order for fried egg.
On 6/6/23 at 0733 hours, Resident 68 was observed receiving his breakfast meal plate with the two fried eggs, and upon cutting the fried eggs on the plate, the egg yolk flowed out in liquid form in which Resident 68 ate it.
On 6/6/23 at 0749 hours, an observation was conducted of the DSS in the kitchen. The DSS cooked fried eggs on the grill for Resident 7 and 96's breakfast meal. The DSS placed the two fried eggs on the meal trays for Residents 7 and 96. The tray cart was delivered to the nursing station to be served.
On 6/6/23 at 0938 hours, a concurrent observation and interview was conducted with the DSS. The DSS was asked if the eggs used to cook the fried eggs for breakfast were pasteurized. The DSS replied the eggs were pasteurized. The DSS was asked to verify if the eggs were pasteurized. Upon examination, the DSS was unable to verify the eggs were pasteurized.
Review of the invoices of the eggs dated 5/25 and 5/31/23 showed the eggs were not pasteurized.
2. According to USDA Food Code 2022 Section 3-501.13 Temperature and Time Control: Thawing showed time/temperature control for safety food shall be thawed completely submerged under running water with sufficient water velocity to agitate and float off loose particles in an overflow.
According to USDA Food Code 2022 Section 3-501.14 Temperature and Time Control: Cooling showed cooked time/temperature control for safety food shall be cooled:
- Within 2 (two) hours from 135 degrees Fahrenheit to 70 degrees Fahrenheit and,
- Within a total of 6 (six) hours from 135 degrees Fahrenheit to 41 degrees Fahrenheit or less.
According to USDA Food Code 2022 Section 3-501.15 Cooling Methods showed cooling shall be accomplished by:
- Placing the food in shallow pans;
- Separating the food into smaller or thinner portions;
- When placed in a cold holding equipment, food containers in which food is being cooled shall be loosely covered or uncovered during the cooling the cooling period to facilitate heat transfer from the surface of the food.
Review of the facility's P&P titled Cooling and Reheating Potentially Hazardous Foods (PHF) also called Time/Temperature Control for Safety (TCS) dated 2018 showed Corrective Action- Discard cooked, hot food immediately when the food is: above 70 degrees F or more than two hours into the cooling process.
Review of the facility's document titled Cook's spreadsheet dated 6/6/23, Week 1 Tuesday, showed Herb and Spice Roast Beef with Gravy for the lunch meal.
On 6/5/23 at 0843 hours, an observation of meat thawing in the sink, and concurrent interview was conducted with [NAME] 1. In a sink next to the manual dishwashing sink, a deep metal pan containing a frozen meat which was partially submerged in water while the faucet water trickled on was observed. Water temperature was 70 degrees Fahrenheit. [NAME] 1 verified the frozen meat of roast beef was in the process of thawing, but she did not know how long the frozen meat could stay submerged in the water. [NAME] 1 further stated they usually did not thaw the frozen meat in the sink, but they forgot to take the frozen meat out the previous day to thaw and planned to cook it for lunch.
On 6/5/23 at 1206 hours, roast beef meat was observed in the oven in the process of cooking.
On 6/5/23 at 1545 hours, concurrent observation and interview was conducted with the DSS regarding the roast beef. A large steam table pan covered tightly with foil labeled roast beef was observed in the walk-in refrigerator. Using the surveyor's thermometer, the temperature of the roast beef was 121 degrees Fahrenheit. The DSS verified the findings.
Review of the facility's Cooling Log book on 6/5/23, showed [NAME] 1 documented the temperatures of the cooked roast beef as follows:
- at 1200 hours, the roast beef's temperature was 140 degrees Fahrenheit,
- at 1430 hours, the roast beef's temperature was 70 degrees Fahrenheit.
The DSS verified the documentation in the Cooling Log book at 1430 hours, was inaccurate, and stated she would reheat the roast beef to 165 degrees Fahrenheit and cool the meat down again.
On 6/6/23 at 0612 hours, interview as conducted with the DSS. The DSS stated she discarded the roast beef from yesterday because the meat was not cool down in time.
3. Review of the facility's P&P titled Labeling and Dating of Foods dated 2023 showed the food items will need to be labeled with an opened date and used by the date that follows the various storage guidelines.
On 6/5/23 at 0821 hours, a concurrent observation and interview was conducted with [NAME] 1 in the walk-in refrigerator. The following was observed and verified:
- Three unopened packages of sliced turkey meat with the expiration date of 5/22/23
- One opened package of sliced turkey meat (with 1/4 of turkey meat left in the package) with the expiration date of 5/22/23
- Two plastic bins containing nutritional shake supplements dated 4/7-4/27/23, and 5/11- 5/26/23.
Cook 1 stated she would discard the expired four packages of sliced turkey meat. [NAME] 1 stated the facility followed the expiration date printed on the nutritional shake supplement carton.
On 6/5/23 at 1005 hours, an interview was conducted with the DSS. The DSS stated the nutritional shake supplements were frozen and taken out to defrost in the bins. The DSS was not sure how long the shakes were good once thawed. Upon inspection of the nutritional shake carton, the DSS verified the nutritional shakes were good for 14 days once thawed.
4. Review of facility's P&P titled Storage of Food and Supplies dated 2018 showed all the food and food containers are to be stored six inches off the floor and on clean surfaces in a manner that protects it from contamination.
During the initial tour of the kitchen with [NAME] 1 on 6/5/23 at 0821 hours, the following was observed and verified in the walk-in refrigerator:
- Two plastic bins containing a mixture of vanilla and chocolate nutritional shake supplements were on the floor under the produce storage rack.
- One steam table pan of jellow was under the storage rack with a pan of thawing chicken meat.
On 6/5/23 at 1005 hours, an interview was conducted with the DSS. The DSS stated it was not okay to store the food on the floor and would discard the jello.
5. Review of the facility's P & P titled Labeling and Dating of Foods dated 2023 showed all the food items in the storeroom, refrigerator, and freezer need to be labeled and dated.
On 6/5/23 at 0821 hours, an initial tour of the kitchen was conducted with [NAME] 1, and the following was observed and verified:
- One pitcher of nectar milk was not labeled or dated.
- Bin #2 was labeled as oatmeal but contained flour, with the best by date of 4/4/23.
- Bin #3 was labeled as flour but contained dry oats, with the best by date of 4/4/23
On 6/5/23 at 1010 hours, an interview was conducted with the DSS. The DSS verified the pitcher of the nectar milk and the two bins containing the flour and dry oats should have an appropriate label and dates of the expiration.
6. According to the USDA Food Code 2022 Section 2-402.11 Hair Restraints: Effectiveness, food employees shall wear hair restraints, such as hats and hair nets or coverings to effectively keep hair from contacting exposed food, clean equipment, and utensils.
On 6/6/23 at 0748 hours, an observation was conducted in the kitchen. A dishwashing machine vendor entered the kitchen without a hair net. The DSS verified the observation and stated the vendor should have worn a hair net.
7. According to the USDA Food Code 2022 Section 4-202.11 Cleanability: Food-Contact Surfaces, multiuse food-contact surfaces shall be smooth and free of breaks, open seams, cracks, chips, inclusions, puts, and similar imperfections.
Review of the facility's P&P titled Sanitation dated 8/1/23, showed the plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded.
On 6/6/23 at 0612 hours, a concurrent observation and interview was conducted with the DSS. Seven bowls were observed on a storage rack. The bowls' glaze was worn off with multiple scratch marks. Two green cutting boards were marred (disfigured) with deep scratches. The DSS verified the observations and stated she would work on replacing the dishware and cutting boards.
8. According to the USDA Food Code 2022 Section 4-602.13 Cleaning of Equipment and Utensils: Frequency of Nonfood-Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude (prevent from happening) accumulation of soil residues.
Review of the facility's P&P titled Sanitation dated 8/1/23, showed the Maintenance Department will assist the Food and Nutrition Services as necessary in janitorial duties which Food and Nutrition Services employees cannot do.
On 6/5/23 at 1003 hours, a concurrent observation and interview was conducted with DSS in the kitchen. The following were observed:
- A ventilation fan cover located in the walk-in refrigerator had a gray and rust-colored residue on its grill.
- A ventilation hood located over the cooking grill and stove had a gray residue on the filters.
The DSS verified the ventilation fan and hood were not clean. The DSS stated the Maintenance Supervisor sometimes cleaned the ventilation fan and an outside company had previously cleaned the ventilation hood.
On 6/5/23 at 1040 hours, a concurrent observation and interview was conducted with the Maintenance Director. After looking at the ventilation fan and hood, he verified the ventilation fan and hood were dirty and stated he did not clean kitchen equipment. The Maintenance Director further stated there was an outside company that cleaned the kitchen equipment. The Maintenance Director stated he fixed the kitchen equipment upon request. The Maintenance Director stated the maintenance requests were logged in a book at each nursing station.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected multiple residents
Based on observation and interview, the facility failed to ensure the results of the most recent recertification and abbreviated surveys were in a place readily accessible to the residents and public....
Read full inspector narrative →
Based on observation and interview, the facility failed to ensure the results of the most recent recertification and abbreviated surveys were in a place readily accessible to the residents and public. This failure posed the risk of the residents, their families, and visitors not being able to examine the most recent survey results and the facility's plan of corrections.
Findings:
On 6/13/23 at 0805 hours, an observation and concurrent interview with the DON and Maintenance Director were conducted. The most recent survey results binder was not present in a place readily accessible and could not be found. The DON verified this findings.
On 6/13/23 at 1457 hours, an interview with the Administrator was conducted. The Administrator further verified the recent survey folder was nowhere to be found.
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure an accurate coding of the MDS was completed for one ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure an accurate coding of the MDS was completed for one of 27 final sampled residents (Resident 118).
* Resident 118 was inaccurately code for the PASRR (Pre-admission Screening and Resident Review). This failure posed the risk of the resident not receiving an individualized plan of care based on the resident's specific needs.
Findings:
Medical record review for Resident 118 was initiated on 6/6/23. Resident 118 was initially admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 118's PASRR dated 5/5/23, showed the resident had no mental illness and there was no level II evaluation was required. However, when Resident 118 was readmitted to the facility, there was another PASRR evaluation for Resident 118 dated 5/18/23, that indicated Resident 118 had mental illness and required a level II evaluation.
Review of Resident 118's MDS dated [DATE], Section A under PASRR, showed Resident 118 had no serious mental illness and did not require to have a level II evaluation. However, under Section I for active diagnosis, Resident 118 had a psychiatric/mood disorder diagnosis.
On 6/8/23 at 1208 hours, an interview and concurrent medical record review for Resident 118 was conducted with the MDS Coordinator. The MDS Coordinator stated the MDS Coordinator was responsible for the PASRR screening for the resident before admission to the facility. The MDS Coordinator stated she completed the PASRR form and submitted it right away and received a letter for the resident if the resident had mental illness and needed level II evaluation, then the MDS Coordinator called the department and followed up for the evaluation. The MDS Coordinator was asked about the MDS coding for Resident 118's PASARR and the MDS Coordinator verified the resident was coded negative for mental illness. The MDS Coordinator verified Resident 118's diagnosis of psychiatric disorder. The MDS Coordinator was asked about the other PASRR evaluation dated 5/18/23, and verified Resident 118 was assessed as positive for mental illness and required a level II evaluation. The MDS Coordinator verified the MDS had not been corrected and the MDS Coordinator should have sent a correction for the MDS when Resident 118 had a positive PASRR level 1 evaluation.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Garbage Disposal
(Tag F0814)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and facility document review, the facility failed to ensure the waste was properly contained and transported when:
1. Three of three dumpsters were overflowing prevent...
Read full inspector narrative →
Based on observation, interview, and facility document review, the facility failed to ensure the waste was properly contained and transported when:
1. Three of three dumpsters were overflowing preventing closure of the dumpster lid.
2. Kitchen trash was not covered during transportation.
These failures had the potential for harborage and feeding of pests.
Findings:
According to the USDA Food Code 2022 Section 5-501.113 Covering Receptacles, receptacles and waste handling units for refuse shall be kept covered after they are filled and with tight fitting lids or doors if kept outside the food establishment.
Review of the facility's P&P titled Miscellaneous Areas: Garbage and Trash dated 2018 showed all food waste must be placed in sealed containers.
1. Upon entering the facility on 6/5/23 at 0730 hours, three dumpsters near the kitchen back door area were observed. Each dumpster was over filled preventing the dumpster lids from closing.
On 6/5/23 at 1155 hours, an interview was conducted with Maintenance Supervisor. The Maintenance Supervisor verified and stated the trash pickup was done every day, except Sunday, but the dumpsters should not be overflowing.
2. On 6/6/23 at 0938 hours, an observation of the kitchen trash disposal was conducted with Dietary Aide 1. Dietary Aide 1 transported two trash cans from the kitchen to the dumpster located in the parking lot without covering the trash cans.
On 6/6/23 at 0956 hours, interview was conducted with the DSS. The DSS verified the above findings and stated the trash cans should be covered when transported out to the dumpsters.
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to follow the physician ' s order for th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to follow the physician ' s order for the administration of pain-relieving medications and interventions for one of two sampled residents (Resident 1) as evidenced by:
* Resident 1 experienced a post-surgical mild pain for over 13 hours before receiving the ordered pain medication.
* Resident 1 received the wrong dose of pain medication on two separate instances.
These failures had the potential for not providing the comprehensive person-centered care and managing the resident ' s pain.
Findings:
Review of the facility ' s P&P titled Administering Medications revised 4/2019 showed the following:
- Medications are administered in accordance with prescriber ' s orders, including any required time frame.
- Medication administration times are determined by resident need and benefit, not staff convenience.
Review of Resident 1 ' s medical record was initiated on 5/3/23. The medical record review showed Resident 1 was admitted to the facility on [DATE], with a diagnosis of joint replacement to the right knee.
a. Review of Resident 1 ' s physician ' s orders showed the following orders:
- dated 10/5/22, for monitoring the pain levels using the pain scale of 0 to 10 with 0 = no pain, 1-4 = mild pain, 5-6 = moderate pain, and 7-10 = severe pain.
- dated 10/5/22, for Oxycodone-Acetaminophen(pain medication) Tablets 5-325 mg onetablet by mouth every six hours PRN for moderate pain.
- dated 10/5/22, for Oxycodone-Acetaminophen Tablets 5-325 mg two tablets by mouth every six hours PRN for severe pain.
Review of Resident 1 ' s Pain Observation/assessment dated [DATE] at 1639 hours, showed Resident 1 reported a pain level of 4 (mild pain as per the physician ' s order for pain scale) to the right knee. However, review of Resident 1 ' s MAR dated 10/5/22, showed Resident 1 did not receive any interventions or medications for pain as ordered by the physician until 10/6/22 at 0556 hours.
On 5/11/23 at 1310 hours, a concurrent interview and medical record review for Resident 1 was conducted with the DON. The DON verified Resident 1 had waited over 13 hours for pain management and should not have.
b. Review of Resident 1 ' s physician ' s orders showed the following orders:
- dated 10/5/22, for monitoring the pain levels using the pain scale of 0 to 10 with 0 = no pain, 1-4 = mild pain, 5-6 = moderate pain, and 7-10 = severe pain.
- dated 10/5/22, for oxycodone-acetaminophen tablets 5-325 mg one tablet by mouth every six hours PRN for moderate pain.
- dated 10/5/22, for oxycodone-acetaminophen tablets 5-325 mg two tablets by mouth every six hours PRN for severe pain.
Review of Resident 1 ' s MAR dated 10/2022 showed Resident 1 received one tablet of oxycodone-acetaminophen tablets 5-325 mg instead of two tablets for the following dates and times:
- 10/6/22 at 1203 hours, for a reported pain level of 7 (severe pain)
- 10/8/22 at 1306 hours, for a reported pain of 7 (severe pain)
On 5/11/23 at 1310 hours, a concurrent and medical record review for Resident 1 was conducted with the DON. The DON verified Resident 1 should have received two tablets of oxycodone-acetaminophen Tablets 5-325 mg for their level of severe pain and did not.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sample...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) remained free from accident hazards.
* The facility failed to ensure the bed alarm (a device that contains a sensor that triggers an alarm when they detect a change in pressure) was properly attached to Resident 1's bed as ordered by the physician after Resident 1 sustained a fall. This failure had the potential for Resident 1 to sustain recurrent falls and serious injury.
Findings:
Review of the facility's P&P titled Falls and Fall Risk, Managing revised March 2018 showed under the section titled Resident-Centered Approaches to Managing Falls and Fall Risk, the use of alarms will be monitored for efficacy and the staff will respond to alarms in a timely manner.
Medical record review for Resident 11 was initiated on 4/11/23. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's History and Physical examination dated 3/12/23,showed Resident 1 did not have the capacity to understand and make decisions.
Review of Resident 1's Order Summary Report showed a physician's order dated 3/27/23, to implement a Position Sensory Alarm (PSA) in bed due to Resident 1's poor safety awareness.
Review of Resident 1's care plan of care showed a care plan problem dated 3/15/23, to address Resident 1's high risk for falls due to decreased mobility (the ability to move or be moved freely and easily), seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Alzheimer's (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and generalized weakness. The interventions included to implement a bed alarm for safety awareness.
Review of Resident 1's Fall Risk Assessment Evaluation (an assessment to see how likely it is for one to fall) dated 3/14/23, showed Resident 1 was at high risk for falls and had three or more falls in the previous 90 days.
Review of Resident 1's status post fall screens showed Resident 1 had sustained falls in the facility on 3/18, 4/9, 4/10, and 4/13/23.
On 4/11/23 at 1530 hours, Resident 1 was observed lying in bed with the bed alarm sound module placed behind the resident's bed, disconnected from the alarm pad, on the bedside chest of the drawer, and outside of the resident's reach.
On 4/11/23 at 1540 hours, a concurrent observation and interview was conducted with LVN 3. LVN 3 verified Resident 1's bed alarm was not properly connected.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) remained f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) remained free from accident hazards.
* Resident 1 had a diagnosis of dementia and demonstrated a history of wandering behaviors while at the facility. Resident 1 subsequently eloped from the facility and was found by emergency medical services wandering the streets. Resident 1 was then brought to a local hospital emergency department to be evaluated. The facility was unaware Resident 1 had eloped from the facility and was unable to determine how Resident 1 had eloped. After the facility became aware Resident 1 had eloped from the facility, the facility identified 3 resident rooms (Rooms C, D, and E) with malfunctioning sliding door alarms and 2 resident rooms (Rooms A and B) in which the sliding door alarms were not in place. These sliding doors when opened allowed for egress from the facility. This failure posed the risk for Resident 1 to have sustained the injuries as a result of having eloped from the facility.
Findings:
Medical record review for Resident 1 was initiated on 12/7/22. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 1's History and Physical examination dated 7/30/22, showed Resident 1 had a diagnosis of dementia with a history of falls.
Review of Resident 1's MDS dated [DATE], showed Resident 1 had severely impaired cognition.
Review of Resident 1's Wandering Risk Observation/assessment dated [DATE], showed Resident 1 was at risk to wander and had diagnoses of dementia, cognitive impairment, and impacting gait/mobility or strength.
Review of Resident 1's care plan problem titled Cognitive Care Plan revised 11/10/22, showed Resident 1 had a diagnosis of dementia with altered cognition related to forgetfulness.
Review of Resident 1's care plan problem titled At Risk for Falls revised 11/10/22, showed Resident 1 was at risk for falls related to decreased mobility, COVID, hypertension, diabetes, and dementia.
Review of Resident 1's care plan problem titled Risk for Wandering/Elopement revised 11/10/22, showed Resident 1's exit seeking behaviors would be minimized every day and remain at the facility.
Review of Resident 1's SBAR dated 8/29/22 1452 hours, showed Resident 1 was found trying to leave the facility. Resident 1 was holding a bag of belongings thinking he was going to be discharged . Resident 1 was instructed he was not being discharged and to return to his room. Resident 1's family and physician were alerted. Resident 1 was to wear a Wanderguard (a device designed to trigger an alarm when a resident wearing it approaches a monitored door or egress) wristband.
Review of Resident 1's SBAR dated 11/17/22 0830 hours, showed a CNA reported Resident 1 had all his belongings on his wheelchair and stated he was going home. Resident 1 attempted to open the back door multiple times. Resident 1 was provided with reality orientation, distractive materials, and encouraged to attend the activities. Resident 1 stated he had to go home to take care of his family. Resident 1's family stated they would come to the facility to talk with Resident 1. Resident 1's family agreed with use of a Wanderguard to alert the staff to Resident 1's exit seeking behaviors.
Review of Resident 1's Order Summary Report showed an order dated 11/17/22, for Resident 1 to wear a Wanderguard to alert the staff when Resident 1 exhibited exit seeking behaviors.
Review of Resident 1's Nurse's Note dated 11/19/22 at 1226 hours, showed Resident 1 attempted to exit the facility on four occasions, twice through the back door (which alarmed upon opening once) and front door (which alarmed only once as well). A new Wanderguard was applied to Resident 1's left wrist and tested for accuracy and proper alarm sounds. The charge nurses for the day shifts were aware of the situation along with the other day shift staff. At the change of shift, the charge nurse and other staff were made aware of the morning events and informed of a new Wanderguard applied (to Resident 1) and encouraged to monitor Resident 1.
Review of Resident 1's Hospital 1 Emergency Department Provider Note dated 11/19/22 at 2010 hours, showed Resident 1 presented to the hospital emergency department with an altered mental status. Resident 1 had a history of dementia. Resident 1 was brought to the emergency department from the street by the emergency medical services after he was found wandering in the street on foot. Resident 1's past medical history included Alzheimer/dementia with behavioral disturbances. The skilled nursing facility was contacted and Resident 1 was to be sent back to the skilled nursing facility.
Review of Resident 1's Nurse's Note dated 11/19/22 at 2128 hours, showed at 1905 hours, RN 2 received a call from Hospital 1's staff trying to identify a resident who was found wandering in the street. The Hospital 1's staff and RN 2 determined the resident (Resident 1) belonged at the skilled nursing facility. Resident 1 was evaluated at the Hospital 1 emergency department and returned to the skilled nursing facility at 2128 hours. The daytime nursing staff was unaware of what time Resident 1 wandered out of the facility. Resident 1 had a history of trying to wander out of the facility. CNA 1 responsible for Resident 1 that day (11/19/22) reported Resident 1 was trying to leave the facility around 1600 hours and brought Resident 1 back to his room. Resident 1 wore a Wanderguard on his left wrist for safety.
On 12/8/22 at 1258 hours, an interview was conducted with CNA 1. CNA 1 stated she was assigned to care for Resident 1 on 11/19/22, during the evening shift (1500 hours to 2300 hours). CNA 1 stated during her shift, Resident 1 had wandered to the facility back door and set off the facility's Wanderguard alarm. CNA 1 stated Resident 1 was then redirected away from the facility back door. CNA 1 stated she noticed Resident 1 was absent from his room when the dinner trays were delivered at approximately 1735 hours. CNA 1 stated another CNA picked up Resident 1's dinner tray and informed CNA 1 that Resident 1 was still absent from his room; however, a portion of Resident 1's meal had been consumed. CNA 1 stated she believed Resident 1 remained within the facility because a portion of his meal was consumed and CNA 1 had not heard the Wanderguard alarm.
CNA 1 stated the last time she saw Resident 1 in the facility was on 11/19/22, was sometime before 1735 hours. CNA 1 was asked if Resident 1 required more supervision due to Resident 1 having wandered toward the facility's back door and causing the Wanderguard alarm to sound. CNA 1 stated there were not enough facility staff to provide constant supervision of Resident 1 as CNAs were responsible for providing care to other residents, in addition to Resident 1.
CNA 1 stated at approximately 1940 hours, the facility RN informed her that Resident 1 had eloped from the facility and was found at Hospital 1. CNA 1 stated she was unaware Resident 1 had eloped from the facility and was unsure how Resident 1 had eloped from the facility.
On 12/7/22 at 1406 hours, an interview was conducted with RN 2. RN 2 stated she was assigned to care for Resident 1 on 11/19/22, during the night shift (2100 hours to 0700 hours). RN 2 stated Resident 1 was confused and frequently packed his belongings, believing he had been discharged from the facility. RN 2 stated Resident 1 had a Wanderguard in place to alert staff if he attempted to elope. RN 2 stated on 11/19/22, from the time she started her shift (1900 hours), she had not heard the facility's Wanderguard alarm. RN 2 stated she received a call from Hospital 1 staff who asked if Resident 1 resided at the facility. RN 2 then verified Resident 1 resided at the facility. Hospital 1 staff informed RN 2 that Resident 1 was found wandering and brought to Hospital 1. RN 2 stated she was unaware that Resident 1 had eloped from the facility. RN 2 stated status post Resident 1 having eloped from the facility, the maintenance staff found a Wanderguard alarm at the facility was inoperable and subsequently fixed the alarm.
On 12/7/22 at 1525 hours, an interview was conducted with the DON. The DON verified Resident 1 eloped from the facility on 11/19/22. The DON stated after the facility became aware of Resident 1's elopement, the facility checked the functionality of door alarms, which were attached to the sliding doors located in the resident rooms throughout the facility. The DON stated the facility determined resident Rooms A and B did not have door alarms attached to the sliding doors, and resident Rooms C, D, and E were found with malfunctioning door alarms. The DON stated the facility installed the door alarms in Rooms A and B, and ensured the malfunctioning alarms were functioning in Rooms C, D, and E. The DON stated it was the belief of the facility that Resident 1 may have exited through one of the resident room sliding doors that had either a malfunction alarm or did not have an alarm in place.
Apr 2021
22 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to accommodate the needs of...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to accommodate the needs of one of 24 final sampled residents (Resident 22) and one nonsampled resident (Resident 68) as evidenced by:
* The facility failed to ensure Resident 68 was provided with the specific type of call light system that he could use to communicate his needs with the direct care staff.
* The facility failed to ensure Resident 22's call light was within reach.
These failures to accommodate the residents' needs posed a safety risk and potentially delayed care for Residents 22 and 68.
Findings:
1. Review of the facility's P&P titled Quality of Life - Accommodation of Needs revised January 2011 showed the resident's individual needs and preferences shall be accommodated to the extent possible. This includes the need for adaptive devices and modifications to the physical environment, which shall be evaluated upon admission and reviewed on an ongoing basis.
On 4/13/21 at 1510 hours, Resident 68 was observed lying in bed and Resident 68's call light (a push button call light activated by hand) was observed on the floor out of the resident's reach. When asked how he called for help from the staff, Resident 68 stated he called the staffs' names out loud. When asked if he was able to use the push button call light, Resident 68 stated he was unable to use the push button call light because he could not move his hands.
On 4/13/21 at 1515 hours, an interview was conducted with LVN 5. LVN 5 verified Resident 68's call light was on the floor and the type of call light was the push button call light. When asked what type of call light Resident 68 required, LVN 5 stated Resident 68 should have the touch pad call light so Resident 68 could use his head to activate it to call for help.
Medical record review for Resident 68 was initiated on 4/13/21. Resident 68 was admitted to the facility on [DATE], and readmitted to the facility on [DATE].
Review of Resident 68's Initial History and Physical examination dated 11/9/20, showed Resident 68's diagnoses included muscular dystrophy (a disease that causes progressive muscle weakness) and quadriplegia (paralysis of all four limbs).
2. Review of the facility's P&P titled Answering the Call Light dated 2001 showed the residents will have a call light that is within easy reach. The purpose of this procedure is to respond to the resident's requests and needs.
On 4/13/21 at 0819, 0848, and 0901 hours, Resident 22 was observed in bed with the call light button on the floor beside her bed.
On 4/13/21 at 0848 hours, an interview was conducted with Resident 22. Resident 22 stated she was unable to find or reach her call light. Resident 22 stated she was worried that she had lost the call light and was unable to summon for help without the call light by her hand.
On 4/13/21 at 0901 hours, an interview was conducted with CNA 6. CNA 6 was asked to come to Resident 22's room. CNA 6 stated the purpose of the call light was for the residents to get help if they needed it. CNA 6 verified Resident 22 could use the call light. CNA 6 verified the call light was not by Resident 22's hand but was on the floor. CNA 6 verified the call light was not accessible to Resident 22 should she need assistance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain the copy of the r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain the copy of the residents' advance directives in the medical records for two of 24 final sampled residents (Residents 26 and 66). This had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.
Findings:
1. Review of the facility's P&P titled Advance Directives revised 12/2016 showed prior to or upon admission of a resident, the SSD or designee will inquire of the resident, his/her family members, and/or his or her legal representative about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.
Medical record review for Resident 66 was initiated on 04/13/21. Resident 66 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 66's Physician Orders for Life-Sustaining Treatment (POLST) dated 3/11/21, under Section D, failed to show information regarding advance directives was discussed with the patient or legally recognized decisionmaker, and whether or not the resident had an advance directive.
Review of Resident 66's medical record failed to show documented evidence of the advance directive.
On 4/14/21 at 0913 hours, an interview and concurrent medical record review was conducted with SSD. The SSD stated Resident 66 had the advance directive which was supposed to be brought in by the resident's family member. The SSD verified the copy of Resident 66's advance directive was not obtained and maintained in Resident 66's medical record nor was it uploaded to the resident's electronic health record. The SSD stated she inquired about Resident 66's advance directive upon his admission but did not follow up with the resident's family member to obtain a copy. The SSD verified the copy of Resident 66's advance directive was supposed to be maintained in his medical record.
2. Medical record review for Resident 26 was initiated on 4/13/21. Resident 26 was admitted to the facility on [DATE].
Review of Resident 26's MDS dated [DATE], showed Resident 26 had no cognitive impairment.
Review of Resident 26's Physician Orders for Life-Sustaining Treatment (POLST) dated 2/3/21, failed to show whether Resident 26 had an advance directive or not.
On 4/14/21 at 0958 hours, an interview was conducted with Resident 26. Resident 26 stated he had formulated the advance directive in 2014. Resident 26 stated the facility did not ask him for a copy of his advance directive or if he had formulated one.
On 4/14/21 at 1035 hours, an interview was conducted with RN 2. RN 2 stated maintaining the copy of the resident's advance directive was important to ensure nothing against the resident's wishes were done. RN 2 added the advance directive was especially important if the resident had a change in mental status or cognition.
On 4/14/21 at 1108 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD stated the existence or presence of an advance directive should be documented on the POLST form and Social Services admission Assessment for all residents admitted to the facility. The SSD verified upon review of Resident 26's medical record showed no documentation whether Resident 26 had an advance directive or not.
On 4/15/21 at 1000 hours, a follow-up interview was conducted with the SSD. The SSD stated Resident 26 had formulated the advance directive in 2014. The SSD provided the copy of Resident 26's advance directive.
Review of Resident 26's VA Advance Directive: Durable Power of Attorney for Health Care and Living Will showed it was formulated on 10/8/14.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to provide one of 24 final sampled residents (Resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to provide one of 24 final sampled residents (Resident 91) full visual privacy while receiving the treatment. This failure had the potential to violate the resident's right to privacy.
Findings:
Review of the facility's P&P titled Quality of Life - Dignity revised 8/2009 showed staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
On 4/13/21 at 1000 hours, an observation of Resident 91 was conducted with RN 1. Resident 91 was observed in bed receiving the Doppler ultrasound (an imaging test that uses sound waves to measure blood flow moving through the blood vessels) of her bilateral lower extremities. Resident 91's bedroom door and privacy curtains were observed being opened, exposing Resident 91 who was in her diaper with her legs and groin area uncovered to be visible from the hallway. RN 1 verified Resident 91's privacy curtain was not closed during treatment. RN 1 stated all staff including contracted vendors should provide the residents with privacy during care.
Medical record review for Resident 91 was initiated on 4/13/21. Resident 91 was admitted to the facility on [DATE].
Review of Resident 91's MDS dated [DATE], showed Resident 91 had severe cognitive impairment.
Review of Resident 91's History and Physical examination dated 12/10/20, showed Resident 91 was mostly nonverbal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to en...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure two of 24 final sampled residents (Residents 66 and 247) attained and maintained their highest practicable physical well-being.
* The facility failed to follow the physician's order to apply the hard neck collar to Resident 66 when he was out of bed.
* The facility failed to ensure the staff followed the physician's order to monitor Resident 247's surgical wound.
These had the potential for the residents to have complications.
Findings:
1. On 4/13/21 at 0736 hours, Resident 66 was observed lying in bed with a soft neck collar in place.
Medical record review for Resident 66 was initiated on 4/13/21. Resident 66 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of the General Order showed a physician's order dated 3/9/21, showing to apply the hard (neck) collar to Resident 66 when he was out of bed.
Review of Resident 66's History and Physical examination dated 3/12/21, showed Resident 66 had a recent cervical spine fixation (procedure in which a portion of the cervical spine is immobilized to heal fractures) and fusion (surgery that joins selected bones in the neck) secondary to C2 odontoid fracture (a fracture of the second bone in the neck).
On 4/14/21 at 0929 hours, Resident 66 was observed lying in bed with the soft neck collar in place.
On 4/14/21 at 1309 hours, Resident 66 was observed seated in the wheelchair in his room with the soft neck collar in place. Resident 66 stated he always had the same soft neck collar on and it was never removed. When asked if he refused the hard neck collar, Resident 66 stated no.
On 4/14/21 at 1320 hours, an interview was conducted with LVN 8. LVN 8 verified Resident 66 was out of the bed and seated in the wheelchair with the soft neck collar in place. LVN 8 stated he was not sure who was responsible for applying the hard neck collar on the resident, and he did not know how to apply it. LVN 8 stated he had to check to see who was responsible for applying the hard neck collar. Resident 66's hard neck collar was found in the resident's closet by LVN 8.
On 4/14/21 at 1348 hours, an interview and concurrent medical record review was conducted with the Director of Rehabilitation. The Director of Rehabilitation verified the physician's order for Resident 66 was to have the hard neck collar (Miami J) in place while the resident was out of the bed. When asked the purpose of the hard neck collar, the Director of Rehabilitation stated Resident 66 had the cervical fracture and the hard neck collar provided more support to the resident than the soft collar as it had a hard plastic that extended down to the resident's upper back and clavicles. The Director of Rehabilitation stated the nursing staff was responsible for applying the hard neck collar.
2. Medical record review for Resident 247 was initiated on 4/13/21. Resident 247 was admitted to the facility on [DATE].
Review of Resident 247's medical record from the general acute care hospital dated 3/30/21 at 1435 hours, showed Resident 247 had the left VATS (video-assisted thoracoscopic [a procedure in which a small tube called a thoracoscope is inserted through a small incision between the ribs]) with decortication surgery to remove fibrosis (the excision of the thick fibrinous peel from the pleural surface, permitting the expansion of the lung).
Review of the Physician Order Report showed an order dated 4/2/21, to monitor the one stitch at Resident 247's left mid-back surgical site daily until the stitch was removed.
On 4/15/21 at 0947 hours, a wound care treatment observation for Resident 247 was conducted with LVN 9. Resident 247's left mid-back was observed with the surgical wound suture, measuring about 0.5 cm x 0.5 cm. LVN 9 washed her hands, donned gloves, and placed an adhesive dressing on the surgical wound.
On 04/15/21 at 1058 hours, an interview and concurrent medical record review was conducted with LVN 9. LVN 9 verified the physician's order was to just monitor Resident 247's surgical wound on the left mid-back. LVN 9 verified she was not supposed to apply a dressing to the surgical wound. LVN 9 stated she was only supposed to monitor the surgical wound site for redness, drainage, or loosening of the sutures.
Cross reference to F880, example 2.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 24 final sampled residents (Res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 24 final sampled residents (Resident 35) received proper treatment and assistive devices to maintain their hearing abilities.
* Resident 35 had complained of missing her right hearing aid for at least six months before an audiology consultation was arranged. This failure had the potential for Resident 35 to not receive timely and necessary care and services to maintain adequate hearing, independent functioning, dignity, and well-being.
Findings:
On 4/13/21 at 0933 hours, an observation and concurrent interview was conducted with Resident 35. Resident 35 stated she was missing her right hearing aid and having difficulty hearing, especially with the staff wearing the masks. Resident 35 stated her right hearing aid was lost around March 2020. Resident 35 stated she had given her hearing aid to a nurse in the evening to be stored, but when she asked for the hearing aid the next day, the nurse stated she did not have it. Resident 35 stated she had reported the lost hearing aid multiple times to several nurses and doctors over the past year (2020). Resident 35 stated the staff did not investigate her claim of loss in a timely fashion and she was still without her hearing aid.
Medical record review for Resident 35 was initiated on 4/13/21. Resident 35 was admitted to the facility on [DATE].
Review of the Physician Order Report showed a physician's order dated 9/29/14, to obtain an audiology consultation with follow-up and treatment as indicated.
Review of the MDS dated [DATE], showed Resident 35 was cognitively intact and used a hearing aid, and her ability to hear (with hearing aid or hearing appliances if normally used) was adequate.
Review of the MDSs dated 5/21, 8/20, 11/16/20, and 2/11/21, showed Resident 35 was cognitively intact, did not have a hearing aid, and had difficulty hearing in some environments (e.g. when the person spoke too softly or the setting was too noisy).
Review of the Resident Progress Notes showed the physician's entry dated 9/10/20 at 2048 hours, showing Resident 35 stated she wanted her hearing aid and the nurse would assist.
Review of the Resident Progress Notes showed the nurse practitioner's entry dated 10/02/20 at 1108 hours, showing Resident 35 had complained of missing her hearing aid.
Review of the Resident Progress Notes showed the physician's entry dated 11/13/20 at 1718 hours, showing Resident 35 was still complaining of her missing hearing aid. The entry showed Resident 35 had a hearing impairment and the lost hearing aid was discussed with RN 4 to follow up if it could be located.
Review of the Resident Progress Notes showed the physician's entry dated 1/25/21 at 1509 hours, showing Resident 35 asked for her hearing aid and the nurses were to locate the hearing aid.
On 4/15/21 at 0740 hours, a follow-up interview was conducted with Resident 35. Resident 35 stated after a year of missing her hearing aid, she asked the staff member who was responsible for helping her to locate the hearing aid in February 2021. Resident 35 stated she was told by the staff member to contact the facility's social services department. Resident 35 stated she reported the loss of her hearing aid to the SSD herself in February 2021 as she was tired of nothing being done about her lost hearing aid. Resident 35 stated she was very frustrated with the situation and by not being able to hear for a year.
On 4/15/21 at 1131 hours, an interview was conducted with the SSD. The SSD stated when the resident's personal belonging went missing at the facility, the expectation was for the staff to report it to the SSD. The SSD stated once the items were reported missing, the SSD and staff would help the resident look for the missing items. The SSD stated if the facility could not find the hearing aid, the facility would assist the resident to obtain an audiology consultation for the hearing aids and replace the item. The SSD stated the resident or representative party would need to show a receipt for the out of pocket cost for the missing hearing aid and the facility would pay for it. The SSD stated Resident 35 informed her of the missing hearing aid in February 2021. The SSD verified no staff member had reported that Resident 35 was missing her hearing aid. The SSD stated Resident 35 informed her that she had been missing the hearing aid for about a year. The SSD stated if Resident 35's missing hearing aid had been reported to her by the staff, Resident 35 could have had a replacement hearing aid sooner. The SSD verified Resident 35 did not have an audiology consultation until 2/25/21, several months after Resident 35's hearing aid had gone missing.
On 4/20/21 at 0824 hours, an interview was conducted with LVN 8. LVN 8 stated the nursing staff was expected to read the physician's progress notes and follow-up on any concerns the physician had documented in the notes. LVN 8 stated if he read the physician's progress note stating the resident was missing their hearing aid, he would report the missing hearing aid to the SSD.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were p...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure injuries for one of 24 sampled residents (Resident 21).
* The facility failed to follow the physician's order to apply the bilateral foam heel protector boots to Resident 21. This had the potential for Resident 21 to not receive the necessary care and services to prevent a pressure injury.
Findings:
Medical record review for Resident 21 was initiated on 4/13/21. Resident 21 was admitted to the facility on [DATE].
Review of Resident 21's History and Physical examination dated 10/28/20, showed the resident had diagnoses including Stage 2 pressure injury to the right buttock, history of smoking, and poor appetite.
Review of the MDS dated [DATE], showed Resident 21 had bilateral impairments to her upper and lower extremities and required extensive, two-persons' assistance for bed mobility and transfers. The MDS also showed Resident 21 was at risk for developing pressure injuries and was receiving pressure injury care.
Review of Resident 21's plan of care showed a care plan problem dated 10/26/20, addressing the resident's risk for altered skin integrity related to decreased mobility, dementia, poor appetite, and incontinence. The approaches included to apply bilateral foam boots to Resident 21 when the resident was in bed.
Review of Resident 21's Physician Order Report showed the physician's order dated 10/27/20, to apply bilateral foam boots to Resident 21 when the resident was in bed for skin management. The order further showed to remove the bilateral foam boots during ADL care and for skin checks.
On 4/13/21 at 1006, 1036, 1139, and 1227 hours; 4/14/21 at 0953 and 1541 hours; and 4/15/21 at 0723, 0811, 0840, and 0947 hours, Resident 21 was observed in bed without the foam boots applied to the bilateral feet. Resident 21 was not observed receiving ADL care during these times.
On 4/15/21 at 0955 hours, an observation of Resident 21 was conducted with LVN 2. LVN 2 verified Resident 21 had the physician's order for heel protectors (foam boots) and should be wearing the foam boots when he was in bed. LVN 2 stated Resident 21 had not refused to wear the foam boots. LVN 2 stated Resident 21 should be wearing the boots at the time of this interview. LVN 2 verified Resident 21 was not wearing the foam boots as ordered. LVN 2 stated the bilateral foam boots should be on Resident 21's feet while he was in bed to protect his heels from skin breakdown.
On 4/20/21 at 0903 hours, an interview was conducted with LVN 9 who was the treatment nurse. LVN 9 verified Resident 21 had a history of pressure injuries. LVN 9 verified Resident 21 was at risk for developing additional pressure injuries. LVN 9 verified Resident 21 had the physician's order for the foam boots to be applied bilaterally when he was in bed for skin management and to prevent further skin breakdown. LVN 9 stated the foam boots were a preventative measure against future skin breakdown.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the environment w...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the environment was free of accident hazards for one of 24 final sampled residents (Resident 83).
* Resident 83's bed was not in the lowest position and the floor mats were not placed on both sides of the bed as ordered by the physician. This failure had the potential for Resident 83 to sustain injuries from falling.
Findings:
Review of the facility's P&P titled Safety and Supervision of Residents revised January 2011 showed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. The resident oriented approach to safety addresses safety and accident hazards for individual residents. Implementing interventions to reduce accident risks and hazards shall include ensuring that interventions are implemented correctly and consistently. Bed safety is considered a potential resident risk factor and environmental hazard.
Review of the facility's P&P titled Physician Orders revised June 2013 showed the physician orders must be given, managed, and carried out in accordance with applicable laws and regulations.
On 4/13/2021, medical record review was initiated for Resident 83. Resident 83 was admitted to the facility on [DATE].
Review of Resident 83's History and Physical examination dated 3/22/21, showed Resident 83's diagnoses included impaired mobility, muscle weakness, left hemiparesis (weakness on one side of the body), and dementia.
Review of the Clinical admission (assessment) dated 3/20/21, showed Resident 83 had intermittent confusion, impulsivity, poor safety awareness, and dementia. The assessment showed Resident 83 was at risk for falls.
Review of the MDS dated [DATE], showed Resident 83 had moderate cognitive impairment, required extensive assistance for mobility, and was unsteady and only able to stabilize himself with staff assistance.
Review of the Resident Progress Notes showed the entries from the IDT dated 3/31, 4/5, and 4/19/21, showing Resident 83 had three unwitnessed falls and was found lying on the floor next to his bed on 3/29, 4/1, and 4/19/21. The IDT entries dated 4/5 and 4/19/21, showed the IDT's interventions and recommendations were to maintain the bed in the lowest position and provide floor mats.
Review of the Rehab Status Post Fall Screen dated 3/29/21, showed Resident 83 had poor safety awareness related to impulsive movements which might have contributed to the fall.
Review of the Physician Order Report showed the physician's order dated 3/30/21, to have floor mats in place on both sides of the bed (every shift) for poor safety awareness.
Review of Resident 83's plan of care showed a care plan problem dated 4/1/21, addressing an actual fall (Resident 83 was found on the floor). The approaches showed to continue using the floor mats and keeping Resident 83's bed in the lowest position with the call light within reach.
On 4/13/21 at 0841 hours, Resident 83 was observed lying in bed. The bed was not in the lowest position and only one floor mat was observed on the left side of the bed.
On 4/19/21 at 1435 hours, an observation of Resident 83 was conducted with RNA 1 and the DSD when Resident 83 was heard calling out for help. Resident 83 was lying in bed and the bed was not in the lowest position. One floor mat was observed on the left side of the bed. No floor mat was observed on the right side of the bed. RNA 1 was observed lowering the bed to the lowest position using the remote. RNA 1 verified the bed was not in the lowest position and there was only one floor mat in place by the bed. The DSD verified the above findings and stated the care plans and physician's orders showed Resident 83's bed should be placed in the lowest position and floor mats should be placed on both sides of the bed.
On 4/20/21 at 1505 hours, Resident 83 was observed asleep in bed which was not in the lowest position. The Corporate Quality Services Nurse was observed entering Resident 83's room. When asked if the bed was in the lowest position, the nurse lowered the bed approximately one foot using the remote and verified the bed was not in the lowest position.
On 4/20/21 at 1515 hours, an interview was conducted with CNA 5. CNA 5 stated when Resident 83 was in bed unattended, there should be floor mats in place on both sides of the bed and the bed should be placed in the lowest position. CNA 5 stated Resident 83 could be severely injured if he tried to get out of bed and the safety precautions were not in place.
On 4/20/21 at 1552 hours, the DON stated if a resident had a fall, the IDT would meet and make safety recommendations. The recommendations were documented on the resident's care plan and the facility staff were expected to follow the recommendations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent urinary tract infections for one of 24 final sampled residents (Resident 86) with indwelling urinary catheters. The facility failed to ensure proper positioning of Resident 86's urinary drainage bag during ADL care to prevent urine from flowing back into the bladder. This posed the risk for Resident 86 to develop a catheter-associated urinary tract infection.
Findings:
Review of the facility's undated P&P titled Indwelling Urinary Catheter showed the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.
On 4/13/21 at 0914 hours, Resident 86 was observed lying in bed with an indwelling urinary catheter in place. Resident 86 was observed being provided ADL care by the Hospice Aide. Resident 86's urinary drainage bag was observed being placed on the bed for the duration of ADL care.
On 4/13/21 at 0921 hours, following the ADL care, an interview was conducted with the Hospice Aide. The Hospice Aide verified Resident 86's urinary drainage bag was placed on the bed during ADL care, but it should have been secured to the bed frame and maintained below the level of the resident's bladder to avoid backflow of the urine to prevent infection.
Medical record review for Resident 86 was initiated on 4/13/21. Resident 86 was admitted to the facility on [DATE].
Review of Resident 86's plan of care showed a care plan problem dated 4/7/21, addressing the indwelling urinary catheter. The approaches included to maintain the urinary drainage bag below the level of the resident's bladder.
On 4/14/21 at 0806 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified Resident 86's plan of care and stated the urinary drainage bag should be placed below the level of the resident's bladder so the urine in the drainage bag did not backflow into the resident's bladder. LVN 4 stated the backflow of the urine into the bladder could cause infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate c...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of a GT for one nonsampled resident (Resident 6).
* LVN 7 failed to flush the GT with water between each medication administered. This failure posed the risk of not maintaining patency of Resident 6's GT.
Findings:
Review of the facility's P&P titled Administering Medications through an Enteral Tube revised November 2018 showed if administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between the medications.
On 04/12/21 at 0805 hours, an observation of the medication administration for Resident 6 was conducted with LVN 7. LVN 7 prepared and administered the following eight medications to Resident 6 via the GT:
- amiodarone (antiarrhythmic medication to treat heart rhythm problem) 200 mg one-half tablet (100 mg ),
- Eliquis (a blood thinner medication) 5 mg one-half tablet (2.5 mg),
- ferrous sulfate (iron supplement) 220 mg/5 ml 7.5 ml,
- Lasix (diuretic medication) 40 mg one tablet,
- Vitamin C (supplement) 500 mg one tablet,
- calcium with Vitamin D (supplement) 500-200 mg one tablet,
- multivitamin with minerals (supplement) one tablet, and
- acidophilus (probiotic) one capsule.
LVN 7 administered the first five medications separately, but failed to flush the GT with water in between each medication administered. LVN 7 flushed the GT with 15 ml of water in between the fifth and sixth medication administered. LVN 7 then administered the remaining three medications at the same time by pouring the three medications into the GT consecutively before allowing each medication to drain completely. LVN 7 was not observed allowing the remaining three medications to drain completely before pouring the next medication, and was not observed flushing the GT with water in between each medication administered. When asked, LVN 7 stated the last three medications administered were the calcium, multivitamins with minerals, and acidophilus. LVN 7 verified he did not flush the GT with water in between administering each medication.
Medical record review for Resident 6 was initiated on 04/12/21. Resident 6 was readmitted to the facility on [DATE].
Review of the Physician Order Report showed a physician's order dated 12/7/20, to flush the GT with 10 ml of water between each medication administered. Cross reference to F759, example #1.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure the peripheral ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure the peripheral IV (intravenous) catheter was maintained as per the facility's P&P for one of 24 final sampled residents (Resident 247).
* Resident 247's IV catheter on the left forearm was not discontinued or assessed for two days after the last IV flush was documented. The second peripheral IV catheter was inserted on Resident 247's right forearm even though the resident did not have the physician's order for IV fluid or IV medication. The IV access on the right forearm was also not labeled with the insertion date. These had the potential to negatively impact the resident's health and well-being.
Findings:
Review of the facility's P&P tilted Peripheral IV Catheter Insertion revised 11/2016 showed the label on the dressing should include the date and time of dressing placement, initials, gauge size, and length of catheter. The P&P further showed to remove the peripheral IV catheter if it has not been used for 24 hours.
On 4/13/21 at 0845 hours, during the initial tour of the facility, Resident 247 was observed with one IV access on his left forearm dated 4/6/21, and another IV access on his right forearm with no date. Resident 247 stated the IVs had not been used and the IV catheter on the right forearm was inserted yesterday. LVN 8 was called to the room and verified the findings.
Medical record review for Resident 247 was initiated on 4/13/21. Resident 247 was admitted to the facility on [DATE].
Review of Resident 247's History & Physical Examination dated 4/2/21, showed Resident 247 had the capacity to understand and make decisions.
Review of the Physician Order Report for April 2021 showed the order dated 4/6/21, with the discontinued date of 4/9/21, to infuse sodium chloride 0.45% solution (a type of IV fluid) at 70 ml/hour intravenously for two liters.
Review of the Physician Order Report for April 2021 showed the order dated 4/7/21, with the discontinued date of 4/11/21, to flush the IV with 10 ml of normal saline before and after each medication administration.
On 04/14/21 at 1117 hours, an interview and concurrent review of Resident 247's IV Administration History dated 4/1 to 4/13/21, was conducted with RN 2. RN 2 verified Resident 247 did not receive any IV fluid or IV medication currently. RN 2 stated the last IV fluid Resident 247 received was documented as completed on 4/9/21 at 2005 hours. RN 2 verified there was no documentation to show the IV was maintained or assessed from 4/11/21.
Further review of Resident 247's IV Administration History showed the new peripheral IV catheter was inserted to the resident's right forearm on 4/12/21, even though Resident 247 did not have the physician's order for IV fluids or IV medications. RN 2 verified there was no documentation to show the IV to the resident's right forearm was maintained or assessed after the IV catheter was inserted on 4/12/21.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the proper respiratory care for one o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the proper respiratory care for one of 24 final sampled residents (Resident 247).
* The facility failed to ensure the physician's order for supplemental oxygen for Resident 247 was followed. This posed the risk of Resident 247 to not receive the proper oxygen therapy to meet their health needs.
Findings:
On 04/13/21 at 0845 hours, Resident 247 was observed sitting in the wheelchair. Resident 247 was observed receiving 0.5 liter per minute of the supplemental oxygen via the nasal cannula. When asked about his breathing, Resident 247 stated he had difficulty breathing yesterday and was supposed to receive two litters per minute of oxygen via the nasal cannula. LVNs 3 and 8 were called to the room and verified Resident 247 had the physician's order for supplemental oxygen at two liters per minute via the nasal cannula. LVN 8 checked Resident 247's oxygen saturation level after LVN 3 had increased Resident 247's supplemental oxygen to two liters per minute. Resident 247's oxygen saturation level was 89% on two liters per minute of oxygen.
Medical record review for Resident 247 was initiated on 4/13/21. Resident 247 was admitted to the facility on [DATE].
Review of Resident 247's medical record from the general acute care hospital dated 3/30/21, showed Resident 247's diagnoses included CHF (congestive heart failure), COPD (chronic obstruction pulmonary disease - a chronic inflammatory lung disease that causes obstructed airflow from the lung), and had a left VATS (video-assisted thoracoscopic [a procedure in which a small tube called a thoracoscope is inserted through a small incision between the ribs]) with decortication surgery to remove fibrosis (the excision of the thick fibrinous peel from the pleural surface, permitting the expansion of the lung).
Review of the Physician Order Report showed the order dated 4/1/21, to administer oxygen at 2 liters per minute continuously via the nasal cannula due to CHF. The goal was to maintain Resident 247's oxygen saturation levels above 90%.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview, facility document review, and facility P&P review, the facility failed to ensure accurate accounting and reconciliation of controlled medications (medications that can cause physic...
Read full inspector narrative →
Based on interview, facility document review, and facility P&P review, the facility failed to ensure accurate accounting and reconciliation of controlled medications (medications that can cause physical and mental dependence, whose use and distribution is tightly controlled due to its potential or risk for abuse) as evidenced by:
* The facility failed to ensure the physical inventory of the controlled medications was conducted during every shift change as per the facility's P&P for one of five medication carts (Medication Cart 1) inspected. This failure posed the risk for the diversion (illegal transfer of any legally prescribed controlled substance) of controlled medications.
Findings:
Review of the facility's P&P titled Controlled Substances revised 12/2012 showed the nursing staff must count the controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the DON.
On 4/20/21 at 1036 hours, an inspection of the medication cart and concurrent facility document review was conducted with LVN 6. LVN 6 stated two licensed nurses had to count the controlled medications at every shift change and documented the counts in the Narcotic Reconciliation Log. Review of the Narcotic Reconciliation Log failed to show documentation that reconciliation of the controlled medications were conducted on the following dates:
- 4/17/21, the 0700 hours to 1500 hours shift,
- 4/18/21, the 0700 hours to 1500 hours shift,
- 4/18/21, the 1500 hours to 2300 hours shift, and
- 4/20/21, the 0700 hours to 1500 hours shift.
LVN 6 stated he had forgotten to sign the log on 4/20/21, under the incoming license nurse's signature. When asked why it was important to reconcile the controlled medications and sign the log, LVN 6 stated to keep track of the controlled medications. LVN 6 verified the above findings.
On 4/20/21 at 1052 hours, an interview was conducted with the DON. The DON verified two licensed staff were required to count the controlled medications and signed the Narcotic Reconciliation Log at each change of shift. The DON stated the process of reconciling the controlled medications was to ensure no medications being diverted away from the residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to act upon a recommendation made by the Pharmac...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to act upon a recommendation made by the Pharmacy Consultant for one of five unnecessary medication sampled residents (Resident 243). The delay of notifying Resident 243's physician of the Pharmacy Consultant's recommendations posed a risk of providing Resident 243 with unnecessary medications and the potential for development of significant side effects.
Findings:
Medical record review for Resident 243 was initiated on 4/13/21. Resident 243 was admitted to the facility on [DATE].
Review of the New admission Medication Regimen Review dated 4/9/21, showed Resident 243 was receiving Reglan (antiemetic medication), Abilify (antipsychotic medication), and Zyprexa (antipsychotic medication). The documentation showed this drug combination increased the risk of extrapyramidal reactions. The Pharmacy Consultant recommended to follow up with the physician in the morning to change the order for Reglan which was not recommended for usage in combination with Abilify and Zyprexa. The Pharmacy Consultant's recommendations also showed Zyprexa and Ativan may increase the effect of Ativan, and for the to monitor CNS depression (central nervous system depression - the body's normal neurological functions slow down).
On 4/15/21 at 0759 hours, an interview and medical record review was conducted with RN 5. RN 5 verified the Pharmacy Consultant's recommendations on 4/8/21 was not acted upon by the facility staff, and was not communicated with Resident 243's physician.
On 4/19/21 at 1208 hours, an interview and medical record review was conducted with the Pharmacy Consultant about Resident 243's Medication Regimen Review (MRR) on admission. The Pharmacy Consultant stated on admission, the Pharmacy Consultant would perform the MRR, and dispense the medications. If the Pharmacy Consultant found some concerns, they would recommend to adjust the medications in the MRR. The Pharmacy Consultant expected the licensed nurses to notify the resident's physician when a recommendation was made. The Pharmacy Consultant stated she recommended the facility to watch for increase side effects and interaction of the combination of the medications for Resident 243. Cross reference to F758.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of five unnecessary medication sam...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of five unnecessary medication sampled residents (Resident 243) was free from unnecessary medications.
* Resident 243 received multiple psychotropic medications. The facility failed to identity and monitor the potential harmful side effects associated with the use of these medications. This failure posed risk of delayed necessary medical intervention necessary for the resident experiencing potential side effects from the psychotropic medications.
Findings:
According to Lexicomp (a reference guide for healthcare professionals) US Black Box Warning updated 4/23/21, Reglan (metoclopramide, antivomiting medication) may cause tardive dyskinesia, a serious movement disorder that is often irreversible with no known treatment; the risk of developing tardive dyskinesia increases with duration of treatment and total cumulative dose. Discontinue metoclopramide in patients who develop sings/symptoms of tardive dyskinesia, in some patients, symptoms may lessen or resolve after metoclopramide is stopped. Avoid treatment with metoclopramide for longer than 12 weeks because of the increased risk of developing tardive dyskinesia with longer term use. Avoid metoclopramide in patients receiving other drugs that are likely to cause tardive dyskinesia (e.g., antipsychotics). Tardive dyskinesia is characterized by disfiguring involuntary movement the face, tongue, and sometimes of the trunk and/or extremities; movement may be choreoathetotic in appearance. Drug interactions of metocolopramide with other antipsychotic agents include: metoclpramide may enhance the adverse/toxic effect of the antipsychotic agents.
Medical record review for Resident 243 was initiated on 4/13/21. Resident 243 was admitted to the facility on [DATE].
Review of the History and Physical Examination dated 4/4/21, showed Resident 243's diagnoses included anxiety, schizoaffective disorder, and bipolar disorder.
Review of the Physician Order Report showed the orders dated 4/8/21, for Zyprexa 10 mg at bedtime for paranoid schizophrenia manifested by delusional statements; Abilify 5 mg once a day for bipolar disorder manifested by severe mood swings; and Reglan 5 mg every six hours for ileus.
Review of the Medication Administration History for April 2021 showed an order dated 4/8/21, for Ativan 0.5 mg every eight hours as needed for anxiety manifested by verbalizations of feeling anxious for 14 days.
On 4/13/21 at 0750 hours, Resident 243 was observed lying in bed. Resident 243 was observed being pale, tired, and lethargic. Resident 243 was asked how she was doing, Resident 243 stated she did not feel well. Resident 243 was asked to further explain how she felt, Resident 243 stated, I felt nauseated, dizzy, I don't think I can make it. The licensed nurse was notified and went to check the resident.
Review of the Behavior Monitoring History for April 2021 showed to monitor for TCAP (T- tardive dyskinesia, C - change in cognitive function, A - akathisia, a movement disorder manifested by inability to stay still, P - Parkinsonism, a condition causing a movement disabilities such as tremor, slow movement, and impaired speech) for the use of Ability and Zyprexa once a day. Review of the monitoring from 4/9 to 4/13/21, showed zero, meaning Resident 243 was not observed with any side effect from the antipsychotic medications.
Further review of the Behavior Monitoring History for April 2021 showed to monitor for the side effects of antianxiety medication including sedation, drowsiness, lethargy, confusion, memory impairment, apathy, fatigue, dizziness, depression, nausea and vomiting, change in appetite, headaches, blurred vision, impaired coordination, possible falls, subdued behavior, withdrawal compare to baseline, or a limitation in functional capacity. Review of the monitoring from 4/9 to 4/13/21 showed zero, meaning Resident 243 had no side effects from the antianxiety medications.
On 4/15/21 at 1217 hours, Resident 243 was observed sitting in the wheelchair calmly and both of her hands were observed shaking.
On 4/15/21 at 1225 hours, an interview was conducted with Physician 1 regarding Resident 243. Physician 1 stated he received the today MRR and agreed with the recommendation of the Pharmacy Consultant to adjust the psychotropic medications. Physician 1 stated he just saw Resident 243. Resident 243 had an extrapyramidal side effects from the antipsychotic medications. Resident 243 received a combination of Reglan, Abilify, and Zyprexa. Physician 1 was asked what extrapyramidal side effects did Resident 243 experienced. Physician 1 stated Resident 243's hands were shaking, and the shaking was a side effect from Reglan. Physician 1 was asked if Resident 243 was groggy, dizzy, and nauseated. Physician 1 stated he agreed with the recommendation, and he would discontinue Reglan and reduce the Ativan to half dose as needed.
On 4/19/21 0854 hours, an observation, interview, and medical record review was conducted with LVN 5 in front of Resident 243's room. LVN 5 was asked how to monitor for behaviors and side effects from the antipsychotic medications. LVN 5 stated she would monitor using TCAP, meaning observe for the uncontrolled movements, cognitive function, and Parkinson's symptoms (tremor in hands, arms and legs). LVN 5 stated the nursing staff documented the number of episodes exhibited for each medication every shift on the Psych TCAP Monitor form in the Medication Administration Record. LVN 5 was asked if she identified any uncontrolled movements from Resident 243. LVN 5 stated no, she did not see any episodes of uncontrolled movements. LVN 5 was asked to observe Resident 243. Resident 243 was observed resting in bed, awake, and her hands were shaking. Cross reference to F756.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication er...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 13.3%. Two of three licensed nurses (LVNs 7 and 8) were found to make the medication errors during the medication administration observation.
* LVN 7 combined three crushed medications and administered them to Resident 6 via the GT.
* LVN 8 failed to administer the medication per the physician's orders for Resident 33.
These failures created the risk for the residents to not receive the therapeutic dose or response of the medications and could negatively affect the residents' health.
Findings:
1. On 04/12/21 at 0805 hours, an observation of the medication administration for Resident 6 was conducted with LVN 7. LVN 7 prepared and administered the following eight medications to Resident 6 via the GT:
- amiodarone 200 mg one-half tablet (100 mg ),
- Eliquis 5 mg one- half tablet (2.5 mg),
- ferrous sulfate 220 mg/5 ml 7.5 ml,
- Lasix 40 mg one tablet,
- Vitamin C 500 mg one tablet,
- calcium with Vitamin D 500-200 mg one tablet,
- multivitamin with minerals one tablet, and
- acidophilus one capsule.
LVN 7 administered the first five medications separately. LVN 7 flushed the GT with 15 ml of water in between the fifth and sixth medication administered. LVN 7 then administered the remaining three medications at the same time by pouring the three medications into the GT consecutively before allowing each medication to drain completely. When asked, LVN 7 stated the last three medications administered were the calcium, multivitamins with minerals, and acidophilus. LVN 7 verified he combined the last three medications. LVN 7 stated he thought he could combine the supplements. LVN 7 verified the policy was to administer each medication separately. Cross reference to F693.
2. Review of the facility's P&P titled Administering Medications revised 3/22/18, showed the medications must be administered in accordance with the orders and the individual administering the medication must check the label to verify the right medication, right dosage, right time, and right route of administration before giving the medication.
On 4/15/21 at 0838 hours, a medication administration observation was conducted with LVN 8. LVN 8 was observed preparing the medications for Resident 33. LVN 8 prepared and administered one tablet of zinc sulfate (supplement) 50 mg to Resident 33.
Medical record review for Resident 33 was conducted on 4/15/21. Resident 33 was admitted to the facility on [DATE].
Review of the Prescription Order dated 3/18/21, showed Resident 33 was to receive one tablet of zinc sulfate 220 mg once a day.
On 4/15/21 at 1331 hours, an interview was conducted with LVN 8. LVN 8 verified the above findings and stated he did not administer the correct dosage of zinc sulfate to Resident 33 as ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely stored and a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely stored and accurately labeled.
* The opened Tuberculin PPD vial (purified protein derivative, a multi-dose injectable solution used to determine if a patient has tuberculosis) was not labeled with the open date or expiration date. This failure posed the risk of the test not showing an accurate result when determining if a resident had tuberculosis.
* The opened Glucose Quality Control Solution (a liquid used to validate the performance of the machine called a glucometer which is used to measure blood sugar readings) bottle did not have an open date and was in use for 30 days beyond the manufacturer's recommended use date. The Glucose Quality Control Solution was used to validate performance of three separate glucometers used for eight residents in the subacute unit of the facility. This failure had the potential for harm related to residents receiving the wrong dose of insulin as a result of glucometers that were not properly calibrated.
* The facility failed to ensure the medication tablets were not free from their containers in the medication cart. This failure posed the risk for medication errors.
Findings:
Review of the facility's P&P titled Administering Medications revised [DATE], showed the expiration dates and open dates must be checked and recorded on the container of multi-dose medications.
1. On [DATE] at 1006 hours, an observation of the medication room in the subacute unit was conducted with RN 1. An open PPD vial was observed in the refrigerator without an open date on it. RN 1 verified the findings. When asked whether RN 1 knew the open date, RN 1 stated she was unaware of the open date.
On [DATE] at 1314 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 verified the PPD vial was last used for Resident 593 on [DATE].
Review of the Manufacturer's Administration Dosage and Administration Guidelines for the Tuberculin PPD vial showed the vials in use for more than 30 days should be discarded due to possible loss of potency.
2. Review of the facility's P&P titled Obtaining a Fingerstick Glucose Level revised [DATE] showed staff must ensure equipment used to check blood sugar levels are working properly by performing calibrations or checks as instructed by the manufacturer.
Review of the Manufacturer's Guidelines titled Evencare G3 Glucose Control Solution showed the solution should be discarded 90 days after the solution was opened.
On [DATE] at 1033 hours, an observation of Medication Cart 1 in the subacute unit was conducted with LVN 6. A box containing the opened Glucose Quality Control Solution was observed without an open date. When asked for the open date and expiration date for the control solution, LVN 6 stated he did not know the open date or when the control solution would be expired.
On [DATE] at 1135 hours, an observation and interview was conducted with LVN 7. LVN 7 stated all three medication carts in the subacute unit shared the same control solution to calibrate the three glucometers used in the subacute unit.
On [DATE] at 1314 hours, a concurrent interview and facility document review was conducted with RN 1. RN 1 verified the above findings. RN 1 verified the control solution was used to calibrate the glucometer performance for the months of January to [DATE] which exceeded the 90-day expiration date according to the manufacturer's recommendation. When asked what could happen if the facility staff used the expired glucose control solution to validate the glucometer performance, RN 1 stated it could lead to an inaccurate blood sugar result being displayed on the glucometer. When asked how many residents in the subacute unit were getting their blood sugar checked using the glucometer, RN 1 accessed the electronic chart and stated eight residents.
On [DATE] at 1348 hours, an interview was conducted with the DON. The DON verified the above findings.
3. On [DATE] at 1314 hours, an observation of Medication Cart 3 was conducted with LVN 5. Loose medication tablets were observed laying at the bottom of the medication cart drawer. When asked what the medications were, LVN 5 stated she did not know. When asked if the medications should be out of the container or package in the medication cart, LVN 5 stated no.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, and the facility failed to honor the dietary pr...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, and the facility failed to honor the dietary preferences for one of 24 final sampled residents (Resident 32) and two nonsampled residents (Residents 16 and 65) as evidenced by:
* The facility failed to ensure Residents 16, 32, and 65 received a lunch tray that matched their dietary preferences. This failure had the potential to cause reduced meal intake and negatively impact the residents' well-being.
Findings:
Review of the facility's P&P titled Resident Food Preferences revised July 2017 showed individual food preferences will be assessed upon admission and communicated to the interdisciplinary team.
1. On 4/13/21 at 1252 hours, a lunch observation was conducted with Resident 32 in her room. CNA 3 was observed to carry in a lunch tray, and then a minute later carried out the same tray after being told by Resident 32 she did not want her tray. The observed lunch tray had a meal ticket dated 4/13/21, showing Resident 32 did not like carrots, fish, and pork. However, observation of Resident 32's meal tray showed the tray had a tuna fish sandwich and carrots.
On 4/13/21 at 1255 hours, a concurrent observation and interview was conducted with CNA 3. CNA 3 stated Resident 32 refused her lunch tray. Upon observation of the meal ticket on the tray, CNA 3 verified Resident 32's tray included fish and carrots. CNA 3 verified both fish and carrots should not be included on the meal tray because they were listed as Resident 32's dislike items.
On 4/13/21 at 1300 hours, an interview was conducted with Resident 32. When asked about her dietary preferences, Resident 32 stated she did not like fish. When asked what type of foods she preferred, Resident 32 stated she liked meat, potatoes, and green vegetables.
Medical Record Review for Resident 32 was initiated on 4/14/21 at 1400 hours. Resident 32 was admitted to the facility on [DATE].
Review of Resident 32's Person-Centered Preferences on the Food and Nutrition Review dated 2/8/21, showed Resident 32 disliked fish.
3. On 4/13/21 at 1207 hours, a lunch dining room observation was conducted. Resident 16 was observed in the dining room drinking. A staff member was observed attempting to feed Resident 16. Resident 16 was observed shaking his head from left to right as if to indicate his refusal of the food offered.
On 4/13/21 at 1213 hours, an observation of the resident's tray and meal ticket showed the resident had a dislike for fish. However, review of the meal tray showed Resident 16 was served fish.
On 4/13/21 at 1218 hours, a concurrent observation of Resident 16's food tray and interview with the RD was conducted. The RD stated the resident preferences were obtained at admission. From there, the dislikes and preferences were put into the computer system for the kitchen. When asked what the process was for following the meal preferences listed for each resident, the RD stated the staff should offer the residents an alternative item. The RD verified Resident 16's meal ticket showed Resident 16 had a dislike for fish. The RD further verified Resident 16 was served fish and should not have been.
2. On 4/13/21 at 1202 hours, a lunch dining room observation was conducted. Resident 65 was observed in the dining room drinking soup from a bowl and pushing the vegetables out of the way. The observed lunch tray had a meal ticket dated 4/13/21, showing Resident 65 did not like vegetable soup.
On 4/13/21 at 1204 hours, an interview was conducted with Resident 65. Resident 65 stated she was not happy with her meal and was served an item she disliked. Resident 65 stated she wanted the plain broth with today's meal. Resident 65 stated she did not like vegetable soup but had been told by staff that she could only have the vegetable soup not plain broth, so she decided to drink only the soup leaving the vegetables in the bowl. Resident 65 stated it was frustrating not being able to get what she liked to eat.
On 4/13/21 at 1208 hours, a concurrent observation and interview was conducted with the IP who was the staff member overseeing the dining room. The IP reviewed the resident's meal ticket on her lunch tray and verified the resident disliked the vegetable soup. The IP verified Resident 65's tray contained the vegetable soup.
On 4/13/21 at 1212 hours, a concurrent observation and interview was conducted with the RD. The RD stated the resident preferences were obtained at admission and every three months or as needed. The RD stated the food preferences were listed on the resident's meal ticket. The RD verified Resident 65 had received the food item (vegetable soup) listed on her dislike list. The RD stated Resident 65 should have been offered something else other than an item from her dislike list. The RD verified the plain broth was available from the kitchen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure Resident 22 received her lunch meal on...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure Resident 22 received her lunch meal on an assistive feeding device known as a divided plate. This failure had the potential for Resident 22 to receive inadequate nutrition.
Findings:
Review of the facility's undated P&P titled Self Feeding Devices showed residents will receive self-feeding devices such as divided plates to maintain or import their ability to eat independently. Residents needing devices will receive them with each meal.
Medical record review for Resident 22 was initiated on 4/13/21. Resident 22 was admitted to the facility on [DATE].
Review of the History and Physical Examination dated 10/21/20, showed Resident 22's diagnoses included a history of CVA (cerebrovascular accident, a stroke which can cause a loss of brain function due to disturbance of blood supply) and functional quadriplegia (complete inability to move due to severe disability).
Review of the Physician Order Report showed an order dated 3/10/21, for mechanical soft diet, thin liquids, divided plate for meals.
Review of Resident 22's meal ticket dated 4/13/21, showed a diet of mechanical soft and the preferences showed divided plate.
On 4/13/21 at 1256 hours, an observation and subsequent interview was conducted with Resident 22. Resident 22 was observed eating her lunch meal in her room. Resident 22 was observed eating diced carrots on a regular plate. Resident 22 was observed to have difficulty eating the carrots which were falling off the plate. Resident 22 stated she typically received her lunch in the divided plate. Resident 22 stated she found it easier to eat her food with the divided plate, so her food did not move or land in her lap.
On 4/13/21 at 1309 hours, an observation and subsequent interview was conducted with LVN 10. LVN 10 reviewed Resident 22's lunch tray and menu. LVN 10 stated the menu showed Resident 22 was to have her meals served on the divided plate. LVN 10 verified Resident 22 did not have her lunch meal served on the divided plate as shown on the meal ticket. LVN 10 stated she did not know the purpose of the divided plate for Resident 22.
On 4/13/21 at 1316 hours, an observation and subsequent interview was conducted with the Dietary Manager. The Dietary Manager verified the divided plates were used by the residents who needed assistance with eating. The Dietary Manager verified Resident 22 did not get her lunch meal served on the divided plate as shown on the meal ticket. The Dietary Manager verified Resident 22 should have received her food served on the divided plate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to
implement the infe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to
implement the infection control practices designed to help prevent the development and transmission of diseases and infections for three of 24 final sampled residents (Residents 247, 443, and 444).
* CNA 2 failed to don the proper PPE when handling soiled linen and failed to perform hand hygiene after providing resident care.
* The facility failed to ensure Residents 443 and 444 had the correct isolation precautions signage to alert anyone entering the room of the required PPE.
* The facility failed to ensure the staff practiced sanitary techniques during wound care for Resident 247. This failure posed the risk of transmission of disease-causing microorganisms.
These failures had the potential for cross-contamination and spread of infectious organisms in the facility.
Findings:
1a. On 4/14/21 at 1118 hours, CNA 2 was observed entering the room of Resident 443 (a resident in the Yellow Unit) without donning the isolation gown, gloves, or performing hand hygiene. CNA 2 was observed picking the linen from the floor with her right ungloved hand and placed it in the white container. CNA 2 was then observed pulling Resident 443's privacy curtain closed with her right ungloved hand. CNA 2 was later observed exiting Resident 443's room without performing hand hygiene.
On 4/14/21 at 1123 hours, an interview was conducted with CNA 2. CNA 2 verified the above findings. CNA 2 verified Resident 443 was on isolation precautions. CNA 2 further verified she did not wear PPE or perform hand hygiene and should have.
b. Review of Resident 443's medical record was initiated on 4/13/21. Resident 443 was admitted to the facility on [DATE].
Review of Resident 443's Physician Order Report showed the physician's order dated 4/8/21, to place Resident 443 on strict isolation with contact and droplet precautions due to being newly admitted .
However, on 4/13/21 at 0846 hours, an observation of the outside of Resident 443's shared room with Resident 444 showed the green signage on the outside of the door. There was no signage to show Resident 443's shared room was in the Yellow Unit. There was also no isolation cart containing the required PPEs needed to enter the room outside of Resident 443's shared room.
On 4/13/21 at 1013 hours, an interview was conducted with LVN 2. When asked what isolation precautions Residents 443 and 444 were under, LVN 2 stated the IP was responsible for the signage. LVN 2 further stated the staff just followed the signage, and as the residents' room had a green sign by the door, the residents were in the green zone. When asked if there was any isolation signage or PPE cart for Residents 443 and 444, LVN 2 stated no. When asked if Residents 443 and 444 should be on the same isolation precautions as the other newly admitted residents in the Yellow Unit, LVN 2 stated no. LVN 2 further reiterated the staff followed the posted signage.
On 4/13/21 at 1038 hours, an interview was conducted with CNA 1. CNA 1 stated she was assigned to Residents 443 and 444. When asked if the residents were on isolation precautions, CNA 1 stated no. When asked how the staff would know which residents were on isolation precautions, CNA 1 stated there needed to be a yellow isolation signage at the door of each resident's room who was on isolation. CNA 1 verified Residents 443 and 444 had a green sign outside of the door. When asked how many timed CNA 1 had entered the residents' room that morning, CNA 1 stated four times. When asked if there was a PPE cart for Residents 443 and 444, CNA 1 stated no because there was a green signage on the residents' door.
On 4/14/21 at 1332 hours, an interview was conducted with the RD. The RD verified there was no Yellow Unit signage on the hallway of the kitchen or on the opposite end of the Yellow Unit to indicate to the residents or staff they were entering an isolation area.
On 4/21/21 at 0748 hours, an interview was conducted with the IP. The IP verified Residents 443 and 444 should have been placed on isolation precautions due to being newly admitted . When asked to describe when the staff should perform hand hygiene, the IP stated the staff should perform hand hygiene before entering the resident's room, between residents, and when leaving the room.
2. According to the Centers for Disease Control and Prevention (CDC), hand hygiene is performed:
- Before and after having direct contact with a patient's intact skin (taking pulse or blood pressure, performing physical examinations, lighting the patient in bed);
- After contact with blood, body fluids or excretions, mucous membranes, non-intact skin or wound dressings;
- After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient;
- If hand will be moving from a contaminated-body site to a clean-body site during patient care; and
- After glove removal.
Medical record review for Resident 247 was initiated on 4/13/21. Resident 247 was admitted to the facility on [DATE], with diagnoses including Stage 3 pressure injury at the coccyx (tailbone) area.
Review of Resident 247's medical record from the acute care hospital dated 3/30/21 at 1435 hours, showed Resident 247 had a surgery to remove a restrictive layer of fibrous tissue overlying the lung.
Review of the Physician Order Report showed a physician's order dated 4/2/21, to clean the sacroccocyx Stage 3 pressure injury with normal saline solution, pat dry, apply Santyl ointment (debriding ointment), and cover with an island dressing (a type of wound dressing) every day for 14 days.
On 4/15/21 at 0947 hours, a wound treatment observation for Resident 247 and concurrent interview was conducted with LVN 9. Resident 247 was positioned on his right side. Resident 247's coccyx area was observed with redness and two open wounds, measuring approximately 1.5 cm x 1 cm. LVN 9 was observed washing her hands and donning the clean pair of gloves. LVN 9 was observed cleaning the wound with normal saline, then patted it dry with a gauze. Without removing the soiled gloves and sanitizing her hands, LVN 9 used the tongue depressor to apply the Santyl ointment to the wound, and covered the wound with an adhesive dressing. LVN 9 continued to perform the wound treatment on the resident's left mid back. Resident 247's left mid back was observed with a surgical wound with sutures. LVN 9 washed her hands, donned a pair of gloves, and applied the adhesive dressing to the surgical wound on the left mid back without cleaning the surgical wound.
LVN 9 verified she did not wash her hands and don a clean pair of gloves before applying the Santyl ointment, and covered the wound with a dressing on the sacroccocyx Stage 3 pressure injury. LVN 9 also verified she did not clean the left mid-back surgical wound before covering the surgical wound with the adhesive dressing. Cross reference to F684, example #2.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 24 final sampled reside...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 24 final sampled residents (Resident 72) received the pneumococcal vaccine (an injection given to protect from severe pneumococcal disease), creating a risk of poor health outcome.
Findings:
Review of the facility's P&P titled Pneumococcal Vaccine dated 10/17 showed pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused).
Medical record review for Resident 72 was initiated on 4/13/21. Resident 72 was admitted to the facility on [DATE].
Review of Resident 72's Informed Consent - Pneumococcal Vaccine dated 9/24/20, showed the facility obtained the consent from Resident 72's responsible party to administer the pneumococcal vaccine on 9/24/20.
Review of the medical record failed to show documentation the pneumococcal vaccine was administered to Resident 72.
On 4/16/21 at 1031 hours, medical record review and concurrent interview was conducted with RN 3. RN 3 verified Resident 72 should have received the pneumococcal vaccine based on the consent form. RN 3 reviewed Resident 72's health record and could not find documentation the pneumococcal vaccine was administered to Resident 72.
On 4/16/21 at 1059 hours, an interview was conducted with the IP. The IP verified the above findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and facility P&P review, the facility failed to follow proper sanitation and food storage practices.
* The facility failed to ensure the kitchenware and tableware wer...
Read full inspector narrative →
Based on observation, interview, and facility P&P review, the facility failed to follow proper sanitation and food storage practices.
* The facility failed to ensure the kitchenware and tableware were properly stored so that only the handles were touched by the dietary staff.
* The facility failed to ensure the stove hood was free of brown material.
* The facility failed to ensure the personal belongings (radio) was stored away from clean dishware.
* The facility failed to ensure the equipment used for the puree preparation was air dry prior to use.
These failures had the potential to cause the foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.
Findings:
Review of the form CMS-672 Resident Census and Conditions of Residents completed by the facility dated 4/13/21, showed 79 of 109 residents residing in the facility received food prepared in the kitchen.
1. According to the USDA Food Code 2017, 4-904.11, kitchenware and tableware, knives, forks, and spoons that are not prewrapped shall be presented so that only the handles are touched by the employees.
On 4/13/21 beginning at 0723 hours, an initial tour of the kitchen was conducted with the assistance of the Dietary Manager. During the tour, one opened drawer was observed with multiple utensils sticking out in different directions without any uniformity to the handles. The Dietary Manager stated in order to prevent contamination, the utensil handles should all be in the drawer in a uniform direction to ensure only the handles would only be touched when retrieving it from the drawer. The Dietary Manager verified the findings.
2. According to the USDA Food Code 2017, 4-602.13, Non-Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
During the initial tour of the kitchen, an observation of the hood above the oven was conducted. A clean, white paper towel was used to wipe along the edge of the hood. A dark brown oily material was noted on the paper towel. This finding was verified with the Dietary Manager.
3. According to the USDA Food Code 2017, 6-305.11, personal belongings can contaminate, food, food equipment and food contact surfaces.
According to the facility's undated P&P titled Sanitation, no radios are allowed in the kitchen.
During the initial tour of the kitchen, an item of personal belongings, a radio, was observed next to the clean dishware. The Dietary Manager stated the personal items such as a radio were not to be stored next to the clean dishes. The Dietary Manager stated the radios were not allowed in the kitchen as per the facility's sanitation policy. The Dietary Manager stated having the radio next to the clean dishes was a sanitation issue and could cause contamination. This finding was verified with the Dietary Manager.
4. According to the USDA Food Code 2017, 4-901.11, after cleaning and sanitizing, equipment and utensils are required to be air dried before contact with food.
According to the facility's undated P&P titled Three Compartment Procedure for Manual Dish Washing, all items washed in the three-compartment sink are air-dried, which means no water droplets are present.
On 4/14/21 at 1001 hours, during the preparation of puree peas, [NAME] 1 was observed providing the blender and lid to the dish staff member. The dish staff member used the three-compartment sink to wash, rinse, and sanitize the blender and lid. The dish staff member was observed giving the wet blender and lid to [NAME] 1. [NAME] 1 proceeded to place the blender on the base and began adding scoops of peas to the wet blender. [NAME] 1 verified the blender was wet inside prior to adding the peas. [NAME] 1 was asked if the blender and lid needed to air dry before adding food item. [NAME] 1 stated she did not know if the blender needed to air dry prior to adding the food item. The Dietary Manager stated the blender and lid needed to be completely air dried prior to adding the food item. [NAME] 1 and the Dietary Manager verified the findings.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected multiple residents
Based on interview, facility document review, and facility P&P review, the facility failed to ensure the most recent survey and complaint investigation results were posted in a public location within ...
Read full inspector narrative →
Based on interview, facility document review, and facility P&P review, the facility failed to ensure the most recent survey and complaint investigation results were posted in a public location within the facility.
* The facility failed to ensure one recent abbreviated survey and one focused infection control survey results were readily accessible to the residents and public for review. This posed the risk for the residents, their families, and visitors not being able to examine the most recent survey results and the facility's plan of correction without having to ask the facility staff.
Findings:
Review of the facility's P&P titled Survey Binder and Survey Results, Posting of Information revised 2/13 showed the facility will make available to the residents the results of past survey information and will ensure that binder is updated regularly.
On 4/16/21 at 1456 hours, a facility document review was conducted. Review of the binder titled CDPH Annual Survey Results located outside the dining/activity room showed the binder contained the past survey results along with the facility's plan of correction. However, the binder did not contain the results of the abbreviated survey dated 12/3/20, and focused infection control survey dated 9/2/20.
On 4/16/21 at 1500 hours, an interview and concurrent facility document review was conducted with the Interim Administrator. The Interim Administrator verified the above findings.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most California facilities.
Concerns
- • 109 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Huntington Valley Healthcare Center's CMS Rating?
CMS assigns HUNTINGTON VALLEY HEALTHCARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Huntington Valley Healthcare Center Staffed?
CMS rates HUNTINGTON VALLEY HEALTHCARE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 54%, compared to the California average of 46%.
What Have Inspectors Found at Huntington Valley Healthcare Center?
State health inspectors documented 109 deficiencies at HUNTINGTON VALLEY HEALTHCARE CENTER during 2021 to 2025. These included: 95 with potential for harm and 14 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Huntington Valley Healthcare Center?
HUNTINGTON VALLEY HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PACS GROUP, a chain that manages multiple nursing homes. With 144 certified beds and approximately 126 residents (about 88% occupancy), it is a mid-sized facility located in HUNTINGTON BEACH, California.
How Does Huntington Valley Healthcare Center Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, HUNTINGTON VALLEY HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (54%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Huntington Valley Healthcare Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Huntington Valley Healthcare Center Safe?
Based on CMS inspection data, HUNTINGTON VALLEY HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Huntington Valley Healthcare Center Stick Around?
HUNTINGTON VALLEY HEALTHCARE CENTER has a staff turnover rate of 54%, which is 8 percentage points above the California average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Huntington Valley Healthcare Center Ever Fined?
HUNTINGTON VALLEY HEALTHCARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Huntington Valley Healthcare Center on Any Federal Watch List?
HUNTINGTON VALLEY HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.